shropshireccg.nhs.uk...Page 1 Shropshire CCG Governing Body meeting – Agenda 8 May 2019 William...

Shropshire CCG Governing Body meeting – Agenda 8 May 2019

William Farr House

Mytton Oak Road Shrewsbury Shropshire

SY3 8XL Tel: 01743 277595

E-mail: [email protected]

A G E N D A

The meeting is to be held in public to enable the public to observe the decision making process.

Meeting Title

Governing Body Meeting Date Wednesday 8 May 2019

Chair

Dr Julian Povey Time 1.30pm

Minute Taker

Mrs Sandra Stackhouse Venue / Location

Shropshire Meeting Room 1, Macdonald Hill Valley Hotel,

Tarporley Rd, Whitchurch, Shropshire SY13 4HA

RESOLVE: A private Governing Body meeting will precede this where it will be resolved that representatives of

the press and other members of the public be excluded having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (section 1(2) Public Bodies (Admission to Meetings) Act 1960).

Dr Julian Povey, Chair

Reference

Agenda Item Presenter Time Paper

GB-2019-05.057 Apologies Dr D Shepherd, Dr M Matthee, Mrs N Wilde, Dr C Stanford

Julian Povey 1.30 verbal

GB-2019-05.058 Members’ Declaration of Interests


GB-2019-05.059 Introductory Comments from the Chair


GB-2019-05.060

Minutes of Previous Meetings Meeting held on 13 March 2019

Julian Povey

1.40

enclosure

GB-2019-05.061

Matters Arising

Julian Povey

1.45 verbal

GB-2019-05.062 Questions from Members of the Public

Questions from members of the public will be accepted in writing 48 hours prior to the meeting and should be submitted by 12.00 noon Monday 6 May to:

Dr Julian Povey, Clinical Chair, Shropshire CCG, Somerby Suite, William Farr House, Mytton Oak Road, Shrewsbury, SY3 8XL or via email: [email protected]

Guidelines on submitting questions can be found at:

Julian Povey 1.50

verbal

mailto:[email protected]



http://www.shropshireccg.nhs.uk/get-involved/meetings-and-events/governing-body-meetings/ A hearing loop system can be made available, upon prior request, to members of the public with hearing difficulties. Please contact the CCG at least 48 hours prior to the meeting.

GB-2019-05.063 GB-2019-05.064 GB-2019-05.065

Clinical and Financial Reports Transforming Care Programme (TCP) Finance and Contracting Report Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) schemes

Dawn Clarke Claire Skidmore Claire Skidmore

1.55

2.05

2.15

enclosure enclosure enclosure

BREAK 2.25

GB-2019-05.067 GB-2019-05.068 GB-2019-05.069 GB-2019-05.070 GB-2019-05.071 GB-2019-05.072

Corporate Performance Reports Quality Exception Report Performance Report

Incl Elective Care – Waiting time management Ambulance Demand Review Future Strategic Commissioning Arrangements STP Operational Plan / CCG Operational Plan Finance Plan for 2019/20

Dawn Clarke Julie Davies Julie Davies/ Gail Fortes-Mayer David Stout David Stout/ Gail Fortes-Mayer Claire Skidmore

2.40

2.50

3.00

3.10

3.20

3.30

enclosure enclosures enclosure enclosure enclosure enclosure

GB-2019-05.073 GB-2019-05.074 GB-2019-05.075 GB-2019-05.076 GB-2019-05.077

Governance & Engagement CCG Approach to Patient and Public Engagement 360 Degree Stakeholder Survey Quality Committee Terms of Reference – for approval Audit Committee – 24 April (summary) Healthwatch Report

Meredith Vivian/ Sam Tilley Sam Tilley Dawn Clarke / Meredith Vivian Keith Timmis Lynn Cawley

3.40

3.50

4.00

4.05

4.15

enclosure presentation enclosure enclosure enclosure

GB-2019-05.078 GB-2019-05.079 GB-2019-05.080 GB-2019-05.081

For Information Only/Exception Reporting Clinical Commissioning Committee – 20 February & 20 March Finance & Performance Committee – 6 February & 6 March Primary Care Commissioning Committee – 6 February Quality Committee – 27 February & 28 March

Sarah Porter Keith Timmis Keith Timmis Meredith Vivian

4.20 enclosures enclosures enclosures enclosures

http://www.shropshireccg.nhs.uk/get-involved/meetings-and-events/governing-body-meetings/




GB-2019-05.082 GB-2019-05.083 GB-2019-05.084 GB-2019-05.085

A&E Delivery Board – 26 March North Locality Board – 28 February Shrewsbury and Atcham Locality Board – 21 February & 21 March South Locality Board – 7 March

Julie Davies Mike Matthee Deborah Shepherd Matthew Bird

enclosures enclosures enclosures verbal

GB-2019-05.086

Any Other Business


Date of Next Meeting

Wednesday 12 June 2019, time and venue to be confirmed

Dr Julian Povey David Stout Clinical Chair Accountable Officer

Minutes of the CCG Governing Body Meeting – 13 March 2019 SCS

Shropshire Clinical Commissioning Group


MINUTES OF THE SHROPSHIRE CLINICAL COMMISSIONING GROUP (CCG)

GOVERNING BODY MEETING

HELD IN THE GARDEN SUITE, THE PARK HOUSE HOTEL, PARK STREET, SHIFNAL, TF11 9BA

AT 1.00 PM ON WEDNESDAY 13 MARCH 2019

Present Dr Julian Povey CCG Chair Dr Finola Lynch Deputy Clinical Chair Dr Simon Freeman Accountable Officer Mrs Claire Skidmore Chief Finance Officer Dr Jessica Sokolov Medical Director Dr John Pepper GP Governing Body Member & Clinical Director Mr Kevin Morris GP Practice Governing Body Member Dr Deborah Shepherd Locality Chair, Shrewsbury & Atcham Locality Board Dr Mike Matthee Joint Locality Chair, North Locality Board Dr Matthew Bird Locality Chair, South Locality Board Dr Priya George GP Governing Body Member & Clinical Director Dr Alan Leaman Secondary Care Member Mrs Gail Fortes-Mayer Director of Contracting & Planning Dr Julie Davies Director of Performance & Delivery Ms Dawn Clarke Director of Nursing, Quality and Patient Experience Mrs Nicky Wilde Director of Primary Care Mrs Sam Tilley Director of Corporate Affairs Professor Rod Thomson Director of Public Health Mr Keith Timmis Lay Member – Performance Mr William Hutton Lay Member – Governance & Audit (Vice Chair) Mrs Sarah Porter Lay Member – Transformation Mr Meredith Vivian Lay Member – Patient and Public Involvement In Attendance Mr Jonathan Bletcher Head of Assurance & Delivery, NHS England Mr David Stout New Accountable Officer wef 1 April – Observer Mr Graham Shepherd Shropshire Patient Group – Observer Ms Vanessa Barrett Healthwatch Shropshire – Observer Mrs Sandra Stackhouse Corporate Services Officer – Minute Taker Sir Neil McKay Chair of Shropshire, Telford & Wrekin Sustainability and Transformation

Partnership (STP) – [For item: GB-2019-03.039] 1.1 Dr Povey welcomed members, observers and the public to the Shropshire Clinical Commissioning

Group (CCG) Governing Body meeting being held in public and advised that the meeting was being live streamed, which would be available to view on YouTube.

Minute No. GB-2019-03.030- Apologies 2.1 There had been one apology noted from:

Dr Stephen James GP Governing Body Member & Clinical Director

Minute No. GB-2019-03.031 - Declarations of Interests 3.1 Dr Povey reported that Members had previously declared their interests, which were listed on the

Governing Body Register of Interests and was available to view on the CCG’s website (www.shropshireccg.nhs.uk/register-of-interest), However, Dr Povey asked Members to confirm any declarations of interest they had in relation to the agenda items and these were noted as follows:

Dr Povey declared that he was a GP Partner at Pontesbury Medical Practice and his wife, Dr Jane Povey, was the Medical Director at Shropshire Community Health NHS Trust (SCHT).

Agenda Item - GB-2019-05.060

CCG Governing Body – 08.05.19

http://www.shropshireccg.nhs.uk/register-of-interest



Dr Sokolov declared that her father was a County Councillor and Governor on the Board at West Midlands Ambulance Service (WMAS).

Dr Pepper declared that he was a GP Partner at Belvidere Medical Practice, which was a Member of the Darwin Group; and was a GP Appraiser for NHS England (NHSE).

Dr Lynch declared that she was a salaried GP at Bishop’s Castle Medical Practice and her husband was a GP Member of Shropdoc.

Mrs Tilley declared that she had a relative who worked at Shrewsbury and Telford Hospital NHS Trust (SaTH).

Mr Morris declared that he was a Managing Partner at Cambrian Medical Practice and his wife was Executive Nurse at Telford & Wrekin CCG.

Mr Vivian declared that his wife was a member of staff at SaTH.

Professor Thomson declared that he was the Director of Public Health at Shropshire Council.

Dr Bird declared that he was a GP Partner at Albrighton Medical Practice; a GP Appraiser for NHSE; and a Member of Shropdoc.

Dr Matthee declared that he was a GP Partner at Market Drayton Medical Practice and his wife was the Practice Manager at the same practice.

Dr Leaman declared that he was previously employed as an A&E consultant at SaTH.

Dr George declared that she was a GP Partner at Market Drayton Medical Practice; a Board Member of Our Health Partnership (OHP); a GP Appraiser for NHSE; and her husband was a consultant at University Hospital North Midlands (UHNM).

3.2 There were no other declarations of interest raised. Minute No. GB-2019-03.032 - Introductory Comments from the Chair 4.1 Dr Povey welcomed Mr David Stout who had been appointed as Shropshire CCG’s new Accountable

Officer from 1st April but was attending the meeting today as an Observer. Dr Priya George was also

welcomed as a new GP Practice Member of the Governing Body. 4.2 Dr Povey thanked Dr Simon Freeman, Professor Rod Thomson and Mr William Hutton for their service

as Board Members as their tenure would come to an end at the end of March. Minute No. GB-2019-03.033 – Minutes of the Previous Meeting – 9 January 2019 5.1 The minutes of the Governing Body meeting held on 9 January 2019 were presented and approved as

a true and accurate record following the implementation of the following amendments: Page 2: delete Dr Sokolov’s declaration of ‘GP Partner at Market Drayton Medical Practice’. Page 10, par 12.2, line 1: change ‘Lynch’ to ‘Ellis’. Page 12, par 14.5, line 2: change ‘bank’ to ‘back’ and par 14.8, line 2: change ‘Powys’ to ‘out of hours’. Page 19, par 18.3, line 4: change ‘APMS’ to ‘APLS’ (advanced paediatric life support).

RESOLVE: MEMBERS FORMALLY RECEIVED AND APPROVED as an accurate record the minutes of

the meeting of Shropshire Clinical Commissioning Group (CCG) held on 9 January 2019 following the implementation of the amendments listed.

ACTION Mrs Stackhouse to action the minor typographical amendments to the minutes. Minute No. GB-2019-03.034– Matters Arising from the Minutes of the Previous Meeting 6.1 An update on the matters arising from the previous meeting was noted as follows:

a) GB-2019-01.268 – Shropshire Care Closer to Home Progress Update Dr Freeman understood the issue regarding the system IT resource to unblock issues preventing data sharing with SCHT and providers was now resolved between Shropshire Community Health Trust (SCHT) and the CCG and it was no longer an issue in the Out of Hospital Programme.

b) GB-2018-11.287 – Questions from Members of the Public

Ms Clarke confirmed that Mrs Bickerton’s comments on her recent patient experience had been fed back via the Clinical Quality Review Meeting (CQRM). Mrs Bickerton had had a good experience at the hospital A&E but had been concerned about some of the food wastage. The Trust had since sent a very comprehensive statement thanking Mrs Bickerton for her comments, which would be forwarded to her.

ACTION: Ms Clarke to forward a copy of the comprehensive statement received from SaTH thanking Mrs Bickerton for her comments.



c) GB-2019-01.008 – Commissioning Landscape Dr Freeman reminded Members that the NHS long term plan sets out the very clear expectation that there will be a single commissioning voice at an STP level. This had a number of different manifestations but the two CCGs have agreed in principle to move towards a single strategic commissioning organisation whilst maintaining appropriate links at a place based level and the interactions with the Councils. This would be taken forward in a paper, which would be presented to the next Governing Body meeting, about the process for that integration which has a significant amount of NHSE requirements around it.

ACTION: Mrs Tilley to bring back a paper about the process for the integration of the two CCGs.

d) GB-2019-01.010 – BeeU (0-25 Mental Health & Well Being Service) Update Dr Davies referred to the Governing Body’s request to bring back a national average comparison of Shropshire’s 0-25s previously reported to have been on medication but unfortunately despite all the various metrics within the NHS, data to provide formal benchmarking had been unavailable. However, the data from an internal audit within the Midlands Partnership Foundation Trust, which compared Shropshire and Staffordshire, had found that Shropshire levels of prescribing were higher but the new model of care was reducing that level. Regarding a progress update on the service, Dr Davies was pleased to report that through the latest Clinical Quality Review Meeting (CQRM) with the provider, it had been confirmed that the Trust had delivered all the additional clinics for the physical health checks screening of all those children who had received high levels of prescribing. No clinical concerns have been raised regarding the physical health of any children. The Trust is now delivering weekly clinics for all children and young people on medication and where physical health checks are required. The CCG has sought additional assurance by an independent review by both the CCGs medication leads and full assurance has been attained on the approach taken by MPFT with regards to those patients. The service continued to be challenged and the commissioners still had some concerns as regards to waiting times and some data quality issues this would continue to be raised through the regular contract meetings and would be escalated up to the Governing Body as required in the future.

e) GB-2019-01.013 – Finance and Contracting Report Dr Davies advised that the work on the WMAS Working Group had been completed and there was a single understanding across the system both at SaTH, WMAS and both CCGs of the underlying data and information and was being taken forward looking at the ambulance demand. Dr Davies had confirmed back to Mr Shepherd that at that point patient representation would be invited to sit on the group which would decide how to manage that demand in a different way.

f) GB-2019-01.014 – Progress Report on Quality, Innovation, Productivity & Prevention (QIPP) Schemes Dr Davies confirmed that she had checked and the Shropshire Orthopaedic Outreach Service (SOOS) did have access to x-rays that were carried out at SaTH. If there was a specific issue there, the CCG was more than happy to investigate further but there had been no underlying reporting issue found.

g) GB-2019-01.015 – Corporate Performance Report It was confirmed that the Governing Body’s concerns about the quality issues had been raised at the subsequent meeting of the SaTH Safety Oversight and Assurance Group. Dr Sokolov added that after further discussion following that meeting, it had been agreed to wait for the outcome of the System Oversight and Assurance Group which had been held the following week. A number of concerns had been raised on an informal basis with the Chair, who was the NHSI Regional Medical Director.

h) GB-2019-01.017 – Provider Quality Exception Report Ms Clarke confirmed feedback was given to improve communications to ensure ED staff were updated on the formal process to follow for the NHS 111 service and an update was expected at the next CQRM meeting. Ms Clarke provided further information on the confidential information leak and the governance breach at the Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH) reported to the Information Commissioners’ Office (ICO). This was considered quite an old information governance breach that had been formally reported to the ICO at the time. As expected, the ICO would wish to see the actions and they had closed off the report to that and all the patients involved were communicated with.



Ms Clarke provided further information on the legal advice sought on the Duty of Candour. Ms Clarke believed this related to an issue the CCG had raised previously with SCHT about clarification on their Duty of Candour requirements because it had not been clear from some of the reports coming through. It had improved and the Director Lead had been asked to provide a report at the next CQRM but Ms Clarke could confirm that the Trust were following the Duty of Candour.

i) GB-2019-01.018 – Cancer Services Update Ms Clarke explained that she had not been able to attend the last meeting and had been unable to obtain the background to the patient care issues as raised by a member of the public but would look into this. ACTION: Ms Clarke to look in to the patient care issues as raised by a member of the public at the 9 January meeting.

6.2 Acknowledgement of Petition - Dr Povey acknowledged receipt of a petition that had been handed in

at the Joint Future Fit Committee from the Shropshire People’s Assembly Against Austerity with regards to questions around the Future Fit process and the changes to services. A written response would be provided at the next meeting. ACTION: A written response would be provided at the next meeting.

Minute No. GB-2019-03.035 – Public Questions 7.1 Dr Povey referred to the questions received from the public which had been submitted in writing.

These were shown on screen with the responses read out by the Director who had provided them. A copy of the questions and answers would be included with the minutes.

Minute No. GB-2019-03.036 – Patient Voice – Frailty Service 8.1 Dr Lynch referred to the paper circulated and introduced a short film produced by NHSE which

showcased the positive impact of the Frailty Intervention Team (FIT) at SaTH on a patient and their family. It was reported that this film was accompanied by a blog on the NHSE website.

8.2 Dr Povey expressed his thanks to the patient and their family for allowing the Governing Body and the

public to view their story. The film showed that although there were challenges within the healthcare system it was possible to redesign services that provided better services for Shropshire patients.

RESOLVE: THE GOVERNING BODY NOTED the positive impact of the Frailty Intervention Team and

the potential for this work to be broadened as the Shropshire Care Closer to Home programme of work develops.

CLINICAL AND FINANCIAL SUSTAINABILITY Minute No. GB-2019-03.037 – Governing Body Assurance Framework (GBAF) 9.1 Mrs Sam Tilley presented the most recent GBAF to the Governing Body and asked that the Board

reviewed the detail of the GBAF risks contained in the document. It was reported that since the document had been presented to the last meeting, it had been reviewed by the Executive Directors and the Audit Committee. The Governing Body was asked to note the amendment to the risk in relation to the CCG’s financial position and delivering its control total. As this was now considered to be a live issue rather than a potential future risk, it had been transferred to the associated issue log for the 2019/20 period.

9.2 Risk 9 Directions - Mr Hutton raised that the Audit Committee had suggested the removal of the

directions element and had questioned whether it was a valid risk on the GBAF given that is was more of a procedural matter rather than a risk to the organisation of achieving its objectives.

9.3 Risk 4 Transformation: Dr Sokolov pointed out that in action (b) the Alliance Agreement had now been signed and the GBAF required updating. In particular, the Governing Body was asked to note the addition of risk No. 11 “Management of 0-25 Health & Wellbeing Service” following the decision taken at the 8 November 2018 Governing Body meeting that this risk should be noted on the GBAF.

9.4 Risk 7 Sustainability of Workforce: Ms Clarke highlighted the impact of this risk across all of the

providers and the impact it could have on delivering some of the transformational change as well as the quality improvement needed. There were local workforce advisory groups in place as part of the Sustainability and Transformation Plan (STP) but it is was about everybody recognising and working



together, not just for health staff and social care staff, but working with private providers to expand and encourage people to come into Shropshire as an exciting place to work.

RESOLVE: THE GOVERNING BODY REVIEWED and CONSIDERED the risks noted on the GBAF and APPROVED the update to the risk/issue of the CCG not meeting its control total for 2018/19 and 2019/20.

ACTION Mrs Tilley to update Risk 4 to reflect the Alliance Agreement had been signed; update the

Risk 7 Sustainability of Workforce to incorporate Ms Clarke’s comments; and remove the directions element in Risk 9.

Minute No. GB-2019-03.038 – Future Fit – Next Steps and Oversight Group 10.1 Dr Freeman gave a verbal update on Future Fit’s next steps and the oversight group. The Future Fit

Joint Committee met on 29th January, the minutes of which were being presented for approval under

Item: GB-2019-03.049. The CCG had received a notification from Telford & Wrekin Council that they would be filing an application to the Secretary of State to review the decision. The position of that referral was unclear as to whether it had been submitted.

10.2 The proposal now was to take forward the production of the next stage of the Strategic Outline Case

(SOC) by SaTH and that work would be undertaken under the direction of an Implementation Oversight Group (IOG) that would be commissioner-led but run with representation of stakeholders around the health community.

10.3 In response to Dr Sokolov’s question asking when the Governing Body would have the detail of the

shape of that group and the timeline going forward, Dr Freeman clarified that the CCG had taken legal advice and it was aware of the extent it could operate whilst the process of the appeal was live. The draft Terms of Reference had been presented to the Programme Board the day before and it was understood there was a series of questions that needed to be answered around how the governance of that would work but broadly the Programme Board were in favour of those Terms of Reference being submitted. Once the Terms of Reference had been agreed they would be presented to the CCG Governing Body for approval.

10.4 Dr Freeman confirmed that the formal process going forward would be run between SaTH and its

regulator. It had been decided within the health community that that process needed a degree of oversight and that also it should be transparent to the public about the work going forward until the SOC had been produced. As noted in the response to questions from the public this month things had changed and, therefore, in terms of the baseline financial assessment, that would have to be taken into account during the next stage of the business case approval process.

RESOLVE: THE GOVERNING BODY NOTED the contents of the verbal update.

Minute No. GB-2019-03.039 – Sustainability and Transformation Plan (STP) 11.1 Sir Neil McKay, Independent Chair for the Shropshire, Telford & Wrekin STP, attended to give an

update on the STP work carried out so far. Sir Neil explained that he was in the process of continuing to meet stakeholders, including Boards, to give initial impressions about how he saw the work of the STP and what it could accomplish with stakeholders.

11.2 It was explained that the 44 STPs covering England were virtual organisations that were meant to

bring together NHS organisations, local authorities and other stakeholders with a view of being able to produce a long-term sustainable service and financial plan. STPs are transient and were due to end in 2021 as it was hoped there would be partnerships in place for Integrated Care Systems (ICSs) and Integrated Care Partnerships (ICPs) which would support statutory bodies and would be more formally recognised as the instrument for drawing partners together to deliver healthcare and to consider strategies.

11.3 A question was posed to the Governing Body that if it was revising the STP plan what were the things

it thought should be considered for inclusion and what involvement the Governing Body would wish to have.

11.4 Sir Neil explained that his first impressions about Shropshire, Telford & Wrekin were that there were

many good services and very good primary care but there was patchy performance in terms of the delivery of the requirements for patients and citizens. Finance was limited and part of the STP’s responsibility was to think about finance across the whole STP. In response to Dr Freeman’s



comments about the governance, Sir Neil confirmed the STP would be happy to have further discussions on this.

11.5 Relationships between organisations were reasonable but could be a lot stronger. To have a

programme of work such as Future Fit was seen as a fantastic resource and it was hoped that it would be possible for communities across the whole of Shropshire, Telford & Wrekin to support Future Fit to enable it to implement a local healthcare service that was very special.

11.6 The STP has a small number of employees but the STP involved all of the statutory organisations,

including the local authorities, and it was pointed out that the STP was only as good as the partnership it was in or was to develop. Sir Neil wanted to ensure there was a deep sense of engagement as it looked to develop the new plan for the next 5 years, which needed to be produced by the autumn.

11.7 The funding associated with Future Fit needed to be used as a catalyst for change. The STP needed

to see that this was not just a SaTH project but one that all partners could contribute to to get the best value for citizens, including hospital services. Strategies for the future could not be built if there was an over-reliance on secondary care or hospitals and enhanced primary care needed to be developed.

11.8 Feedback/questions from the Governing Body to Sir Neil’s question in paragraph 11.3 included the

following which have been summarised:

Members were pleased to note the word ‘simplify’ used as it was considered the process was so complicated that it was easy to lose sight of the aim. It was also good to see that the STP was a way of working and not a body. It would be interesting to see how the STP could change the culture in a system so that partnership working could be easier.

It was asked how the STP was going to help with the large amount of transformational change required. There had been no lay or non-executive input into the programme so far and it would be interesting to hear how the STP saw the non-executive input from the different bodies including the Councils. Sir Neil responded that he would like to see greater involvement and a Senior Leadership Group would put forward ideas for this.

The comment about public engagement and involvement was welcomed and it was pointed out that it was critical to ensure that the engagement with the public in the transformation of services gave the public the confidence that services would be provided when needed and in a sensible way. Sir Neil acknowledged this point and said it was for the STP as a whole to take forward in a way that was appropriate for its needs.

There had been some questions received from members of the public that senior meetings of the STP were not held in public. Sir Neil’s response was that there were a variety of ways of working more transparently and he was open-minded to what the solution might be.

The Board recognised the importance of working together and the advantage of integrated care and were fully signed up to the priorities as described. A recurrent theme was that all partners contributed to a central resource and there had been concerns from the Board on whether it was getting the best use of that resource in the work it needed to do, particularly in terms of Members being able to do their job as well as delivering transformation work. Sir Neil agreed with this comment and said he was very keen to consider the resource and to help with simplifying governance arrangements.

From the Patient Participation Group (PPG) perspective it was considered there needed to be more PPG involvement at every level and there was a lot of people in Shropshire who were very keen to be involved. It was considered involvement in the stakeholder group was too late in the process. Sir Neil reassured Members that “baking in” patient and citizen involvement in the STP work would be considered in the delivery of the 5 year plan. However, the Boards needed to have arrangements in place for that also as well as the STP.

It was considered that a degree of leadership from the STP was required. Relationships with all of the providers were not as good as described but there was the will amongst the clinicians and health professionals to work together in the system. It was felt that the STP could help with facilitating an understanding of the workforce and finance issues, which needed to be shared as a system.

11.10 On a final note, Sir Neil said he had seen a great sense of optimism not just in terms of an ICS but a

range of work. It would be good to see the shadow arrangement with the two CCGs in place as soon as practicable.

11.11 Dr Povey thanked Sir Neil for attending to give the update.



RESOLVE: THE GOVERNING BODY NOTED the contents of the verbal update. Minute No. GB-2019-03.040 – Transforming Care Programme (TCP) 12.1 Ms Clarke briefly explained the background to the TCP, which had been established by NHSE post

the Winterbourne serious case review to support people with learning disabilities with complex needs who have been placed in in-patient facilities but were not given the quality of care that was needed.

12.2 Ms Clarke referred to the paper pre-circulated and highlighted the key issues to note which included:

The TCP used a multi-agency approach to avoid unnecessary hospital admission and was working effectively for the individuals requiring additional support.

There have been challenges discharging patients mainly because they are in active treatment and it would not be appropriate for them to be discharged. For some patients it is because of the geography in Shropshire of finding properties and recruitment of appropriately-trained staff.

At the outset of the programme it had been deemed high risk and that it would not meet the end-March trajectories, however, there were four individuals near to being brought back home and NHSE were fully aware of those cases.

NHSE had provided resource for a consultant to support the TCP to look at whether there was anything more that could be done and his initial findings had been there was excellent collaborative working with no further steps to be taken.

NHSE recently commended the TCP on its implementation of Care and Treatment Reviews (CTR) evidenced as part of an audit of effectiveness undertaken in November 2018.

A multi-disciplinary review of a patient death has been convened as part of the Learning Disabilities Mortality Review (LeDeR) Programme.

The Annual Report had been shared recently by Bristol University because of the good work taking place in Shropshire, Telford & Wrekin about LeDeR mortality reviews. There is a lot of engagement with all of the providers and a number of reviewers that were working closely on the reviews to achieve the outcomes. There was also an action planning team that was taking forward the actions. The outcome would be reported to the Governing Body as soon as it was available.

12.3 Dr Shepherd understood that when the LeDeR programme was first introduced there were possible

penalties if the targets were not met and asked if this was going to apply to the CCG. Dr Shepherd also asked what the next steps were going forward.

12.3 Ms Clarke reported that the CCG did not know whether they would have any money clawed back.

The two CCGs and the two local authorities finance group had asked the question of NHSE. There had been a recent telephone call with the NHSE Director of Adult Social Services who was leading on the TCP programme and Telford & Wrekin Council and it had been felt that there was nothing new that the CCG should be doing.

RESOLVE: THE GOVERNING BODY RECEIVED the contents of the report and NOTED the challenge

in relation to the discharge planning of the CCG individuals. THE GOVERNING BODY NOTED that more detailed reports were considered at the Shropshire TCP Programme Board.

Action: Ms Clarke to present the outcome of the Learning Disabilities Mortality Review (LeDeR)

Programme to the next Governing Body meeting. Minute No. GB-2019-03.041 – Shropshire MSK Development 13.1 Dr Davies explained the purpose of the paper on Shropshire MSK Development was because MSK

services remained a priority for the CCG and recent updates to Right Care information continued to show that Shropshire was an outlier for its level of MSK spend compared to outcomes for patients.

13.2 There were also concerns following the development of the SOOS service around the delivery of the

service and the pace at which that was being successfully delivered. The CCG had undertaken an in-depth audit of that service which showed how the service was being delivered at an operational level and how it was reviewed and held to account and prioritised within RJAH. As a result of that audit, there has been a significant change in commitment from the organisation to address the issues identified in the audit. There had been a significant improvement in the performance indicators of the service in recent weeks. As a result, the Governing Body’s support to continue with that approach was being sought.

13.3 There has been a reduction in primary care demand as a result of the SOOS service and improved

outcomes in terms of conservative management for patients. There has also been an opportunity with



Telford & Wrekin CCG to develop a single system wide model for MSK services that incorporates the best elements of Telford & Wrekin CCG’s TEMS and Shropshire CCG’s SOOS models.

13.4 In order to oversee the development and delivery of that single approach and for a sustainable MSK

service for the system, an MSK Transformation Board that would have very senior level clinical leadership to drive the cultural changes that are needed in the system would be set up.

13.5 In response to Mr Hutton’s query regarding the comment about a tariff premium, Dr Davies explained

that this was an historic arrangement whereby the Trust had identified for certain services the national tariff did not cover the costs of the service to a specialist hospital and there had been agreement for a top-up. The top up had been meant to be on a transition basis but had become permanent. Dr Freeman further clarified that generally specialist hospitals tended to carry out the more difficult revision type of work so their case mix was a lot higher than would be expected from a normal MSK service.

13.6 Mr Timmis commented that given how long it had taken to carry out the MSK SOOS review, he had

some scepticism about why it was worth pursuing with RJAH. Mr Timmis asked if it was going to take a Transformation Board to enable this change, why was the CCG not looking for an alternative partner who would achieve the change instead.

13.7 Dr Davies explained there had been a significant difference in the attitude within the Trust. It was felt

that what also helped was that Dr Freeman had attended a meeting with the chief executive of RJAH, which had set out the CCG’s expectations in that the improvements were not being made at the pace they needed to. This was used as a last chance to improve the service.

13.8 Dr Pepper queried how similar the TEMS and SOOS services were. Dr Davies explained that there

were some similarities but also differences. Both services had been operating for long enough and had recently been reviewed so the strengths and weaknesses of the models of care were known. Therefore, there was an opportunity to combine the intelligence and experience of both services and use that to define a single model that incorporated the best combination of services for patients.

13.9 Dr Freeman explained that at the moment RJAH have signalled their agreement to block down hips,

knees and shoulders to average levels of intervention rates against the SOOS investment with a 50% risk share which appeared entirely reasonable.

RESOLVE: THE GOVERNING BODY:

NOTED the actions taken to date by the CCG and partners to implement an effective SOOS service and the work to develop a joint approach with Telford & Wrekin CCG.

APPROVED continued Shropshire CCG support of the SOOS service, supported by robust performance management arrangements.

NOTED the development of a system MSK Transformation Board that would oversee the development and delivery of MSK services.

CORPORATE PERFORMANCE REPORTS Minute No. GB-2019-03.042 – Finance and Contracting Report and the Quality, Innovation, Productivity & Prevention (QIPP) Report 14.1 Mrs Skidmore presented the Finance and Contracting Report and the QIPP Report, the purpose of

which was to articulate the finance, contracts and QIPP position for end-January 2019 (Month 10) and to highlight any areas of risk. Within the two reports, the following points were highlighted:

Finance • The CCG was reporting that it was off plan year to date by £8.6m, which it was expected to

address in part but not fully by use of available reserves and contingencies. • It was expected that approximately £5m of the CCG’s identified risks could not feasibly be

mitigated before the year-end and the CCG would fail to meet its control total. • The initial control total for the year was a deficit of £13.3m and unmitigated risk of £5m would result

in an overall deficit of £18.3m.

Contracts • The CCG had recently agreed a year-end position with RJAH for 2018/19 that did not significantly

change the position reported for Month 10, which followed the earlier agreement with SaTH already reflected in the position.

• The 2019/20 contract negotiation discussions were underway with all providers and areas of escalation were now being identified. QIPP business cases have been shared with the providers



for 2019/20. The CCG was required to make a decision on whether mediation was required with any of the providers by 1

st March and communicate this to NHSE.

• The CCG was pursuing a number of Contract Performance and Activity Query Notices at SaTH, RJAH, WMAS, MPFT, SCHT, WMAS, and Falck.

QIPP • This had been a very challenging period where Month 10 saw a significant movement in the

forecast outturn largely attributable to under performance across Commissioning. • The QIPP programme at Month 10 had achieved savings of £13.6m against a plan to date of

£16.3m, an under performance of £2.7m. • QIPP savings were forecasted to be £16.1m against a plan of £20.5m. This forecast was a marked

downturn from that reported in Month 9. • The at-risk schemes that were scheduled to deliver in the final quarter have now been closed and

this had been reflected in the forecast outturn. • MSK continued to be an area of interest and there had been a slight improvement seen in the MSK

forecast in Month 11. • Business planning and the Gateway Process for QIPP continued during the period. This has taken

the form of a number of challenge sessions for all schemes in the 2019/20 portfolio and a push from the Accountable Officer to move to business case sign-off.

• CHC continued to give the greatest cause for concern in terms of this year and next year’s QIPP schemes.

• The options for the future of the PMO function were being discussed in conjunction with Finance colleagues at Telford & Wrekin CCG.

14.2 The Governing Body was reminded that the deterioration in this year’s position would have an impact

on the CCG’s finances moving forward. There had been a number of non-recurring elements within the position that had helped the CCG’s position this year but would not be available next year. The CCG had therefore had a significant underlying deficit within its position when carrying that forward into the new financial year and would mean that the CCG would need to work even harder to meet its control total requirements.

14.3 Mr Timmis fed back the following comments made from the last Finance and Performance Committee

meeting:

It had been raised that because there was a number of interim staff whose contracts were due to come to an end at the end of March, concern had been raised that there would be less resource available to work on QIPP and the finance arrangements. It had been identified that there might be resource available in the joint working with Telford and Wrekin CCG but this reflected a significant change and there would be less resource available to try and deliver next year’s control total.

Concern had been raised that some of the opportunities discussed so far at STP level had appeared vague and some of those opportunities might be double-counted.

Regarding MSK services, the view from the Committee was that this was the last chance for RJAH to implement the changes to the service that the CCG had been requesting.

The Committee had also discussed some of the financial pressures in the minor acute contracts in particular and had asked for a follow-up report to be presented at the April meeting to ensure the level of risk reflected in the financial report was accurate.

A long discussion had taken place on whether there was value for money out of year-end agreements. It had been agreed that in the next operational year, the Committee would review the year-end agreements for the key providers. In particular, the Committee had not expected to see extra expenditure on SaTH and had asked for this to be reported back to the Governing Body before it carried out the review of the year-end agreements

The QIPP had been extensively back-loaded into Quarter 4 and that posed an exceptional level of risk at a time when the CCG has been trying to finalise schemes for next year and trying to deliver the schemes for this year.

14.4 Dr Freeman said he totally understood about the comments made about the year-end agreements. Mrs Skidmore explained that the arrangement made with SaTH was around the core contract and some of the regular payments that the CCG made. If an exceptional need did arise that would be deemed to be outside of the contract and would need further consideration. Dr Freeman suggested that there might be some value in bringing back to the Governing Body a more in-depth review of the system wide ambulance demand.

RESOLVE: THE GOVERNING BODY NOTED the contents of the Finance and Contracting and QIPP reports.



ACTION Dr Davies and Mrs Fortes-Mayer to bring back the system wide ambulance demand review to the Governing Body’s next meeting.

Minute No. GB-2019-03.043 – Corporate Performance Report (including Elective Care – Waiting Time Management) 15.1 Dr Davies presented the Corporate Performance Report, which outlined Shropshire CCG’s

performance against all of its key performance indicators for Months 9 and 10 where available for 2018/19. The key standards that were not met year to date for Shropshire CCG were:

62 day RTT

2 wk wait (Breast)

2 wk wait from GP referral

IAPT access

A&E 4 hr target

Ambulance handovers >30 mins and > 1 hr

RTT

52 wk waiters 15.2 It was recognised there had been challenges with cancer services performance, however, there had

been improvements in the individual recovery plans on the tumour site level and in the 2 week performance and a slight improvement in the 62 day RTT.

15.3 The Governing Body’s attention was brought to the fact that the CCG had still not received a detailed

recovery plan for Urology. This was because there were some specific challenges not least because of the way in which urologists were only being trained in robotic surgery. Work was on-going with University Hospital North Midlands (UHNM) in order to create a clinical partnership arrangement with them that was already allowing Shropshire patients to be treated at UHNM where they required the robotic surgery. This would mean that the date for the 2 week waits and the 62 day RTT were unlikely to take place until July 2019.

15.4 A&E performance remained significantly challenged, however, for the first time the trend of year on

year deterioration in performance had been broken and the January 2019 performance was better than the January 2018 performance.

15.5 Mr Timmis reported that the Finance and Performance Committee had expressed its concern about

the Out of Hours (OOH) service and SCHT’s responsiveness on performance data, which had not been received for three months. Issues had also been raised about data quality and workforce.

15.6 Dr Davies confirmed these issues would be raised through the contract process. The CCG intended

to continue to pick this matter up within this report and data would be received going forward. 15.7 Dr Leaman asked what part the NHS 111 service was playing in A&E and with WMAS. 15.8 Dr Davies explained that this was connected to the piece of work that had just been completed and

what the data showed at present was there had been no material impact as a result of the switchover in July 2018 from the Out of Hours’ number to NHS 111. What had been seen was that there had been a reduction in ambulance dispatches linked to 999 but there had been an increase in the ambulance dispatches through NHS 111. The CCG needed to understand what was driving that demand. There had been an increase in conveyance rate and so the key element was how to meet that demand in a different way that reduced the need to convey and this was the challenge the CCG needed to address. The national team was working with the CCG to help build a better model.

15.9 Dr Sokolov reflected that a lot of the concerns referenced in the report should be addressed through

the resetting of priorities that the A&E Delivery Board should be driving forward. There was an understanding of where those priorities should be and a lot of that was around internal processes, ambulatory same day care and short stay capacity and the ability to avoid admissions. Those processes were not in place at present and addressing those concerns in this way should help improvements to be made.

15.10 Mr Shepherd referred to the closure of the new 28 bed ward in the Copthorne building due to not

meeting fire regulations. Mr Shepherd had been informed by one senior consultant that the ward could only use four of the beds in that ward due to shortages of staff.



15.11 Dr Davies explained that there was still some building work required in order for the ward to gain its fire regulation and so at present the ward was being used as a discharge ward for 12 beds for 12 hours a day. The staffing remained a concern and even with the fire regulation being addressed the CCGs were still asking for further assurance around staffing levels. The CCG needed to identify the needs and then work through a plan so that we can deliver that additional capacity as a system.

15.12 Dr Shepherd referred back to the challenges in the Urology service and noted that in the report that

one consultant had been on long term sick leave and another had resigned. Dr Shepherd asked if it was known what the plans were to replace those consultants and how long it was likely to take

15.13 Dr Davies confirmed it was not known how long this would take. The new qualified consultants were

looking for access to use robotic equipment which SaTH did not have. One of the key elements of the partnership with UHNM was to look at having joint appointments to enable patients to have robotic surgery at UHNM and outpatient clinics at SaTH.

15.14 Dr Shepherd commented that she felt uncomfortable about the extra non-recurrent money which had

been paid to SaTH to achieve their RTT target. On the one hand she recognised that this affected patients who were waiting far too long to be seen but equally it felt as though SaTH were being rewarded for not achieving a key target.

15.15 It was explained that the situation was very complex but the CCG’s obligation was to ensure that the

providers provided services for Shropshire patients.

RESOLVE: THE GOVERNING BODY NOTED the contents of the report and the CCG actions contained within to recover performance in those areas which are currently below target.

Minute No. GB-2019-03.044 – Provider Quality Exception Report 16.1 Ms Clarke presented the Provider Quality Exception Report and appendices and assumed Members

had read these. As the Governing Body was aware this was the high level summary of quality issues. A number of those issues had already been included in the Performance Report and were discussed in more detail at the Quality Committee meetings.

16.2 The Governing Body was asked to note that it had been confirmed by SaTH that the Director of

Nursing and Midwifery; the Deputy Director of Nursing and Midwifery; and the Head of Midwifery had resigned from their posts. It was not known what the interim arrangements would be but clearly given the quality improvements required of the Trust as part of the CQC inspections, the work on the serious incident management and the maternity services with the Donna Ockenden Report affecting 250 families, this was a significant risk.

16.3 Ms Clarke read through the key issues and points to note, which included: The West Midlands Quality Review Service had conducted an inspection of Telford and Wrekin and

Shropshire CCG Quality Teams on the 14th and 15

th February. The formal report was expected at the

end of March. The background report was attached at Appendix 3. Ms Clarke reported that the feedback on the day was very positive and they had recognised the improvements in the governance in clinical services within the CCG and the recognition at Governing Body and support that all of the Lay Members and clinicians provided to the quality outcomes for patients. In 2017 there had been inadequate assurance for serious incidents (Sis) and feedback on the day was that there was excellent management of SIs between Shropshire and Telford & Wrekin CCGs. Ms Clarke extended a thank you to all the clinicians and the Quality Team for their involvement in the RCAs and the amount of work they had done in challenging the providers, which had been quite substantial but it had paid dividends in the results seen.

16.4 The CCG had also received positive feedback on the work on mortality, particularly in respect of the

LeDeR mortality reviews undertaken and the collaborative working between the CCGs to ensure that providers are held to account. There had been recommendations, some of which the CCG had already acted upon. The CCG was awaiting receipt of the final report.

16.5 Professor Thomson thanked Ms Clarke and the Quality Team for the intense work they had carried out

at SaTH and commented that it seemed that the CCG was having to spend a disproportionate amount of its time almost managing the services within the Trust to try and improve quality. When looking at activity levels, 12 hour trolley breaches and now with three senior nursing staff leaving, there was a real cause for concern about how the Trust was managing its services and what assurances could be given to the public about the services provided.



16.6 Mr Hutton referred to SaTH’s detailed series of actions in response to the Care Quality Commission

(CQC) visits last year and asked if the CCG had considered whether there was a real addressing of those underlying issues to try and resolve those.

16.7 Ms Clarke advised that the staff were very committed to making the changes that were required.

There were workforce issues and a high use of agency staff which affected the ability to govern and supervise, and support was going to be limited. There were a large number of actions and it was how the Trust could safely introduce those and sustain some of that work, which had been raised at the Safety Oversight and Assurance Group. There was a cause for concern for the CCG about the change of the three senior nurses and the NHSI Director of Nursing was working with the Trust very closely to ensure that arrangements were in place and staff were being supported.

16.8 In response to Dr Leaman’s question about the clinical care capacity at RJAH and to what extent did

that restrict what surgery could be carried out there, it was confirmed that the IT issues had created restrictions in what work could be carried out. Ms Clarke advised there had been aspects that some patients had been transferred to the Trust post-surgery, which had been raised with the CQC and was included in the report. Ms Clarke said she did not have the detail to hand but confirmed that the cases were being reviewed.

16.9 Dr Lynch expressed concern that there were so many actions for SaTH to address that they may lose

sight of what they needed to prioritise. It was suggested whether the CCG could bring together its concerns because that was one area in ensuring the focus was on the right areas. It was acknowledged there was a considerable amount of work to be done but it was also queried how much progress was being made whilst staff continued to work in very fragile conditions.

16.10 Ms Clarke reported that an escalation framework had been put into place that could capture both

environmental workforce and safety complaints, etc for every department. This had been successfully used last year before going to the risk review summit with NHSE in August 2018. It was proposed that this was revisited and updated because different concerns were appearing again.

16.11 It was suggested and agreed the concerns had been highlighted to SaTH and the Trust needed space

to address those concerns. It was agreed that Ms Clarke would discuss further with Dr Sokolov and would share with the Governing Body the structured approach take to escalation of areas of concern.

16.12 Dr Shepherd commented that it was of great concern that the Trust was losing its three senior nurses

but it could also be an opportunity to recruit new staff with new ideas and emerging enthusiasm so it was not completely negative.

16.13 On behalf of the Shrewsbury and Atcham Locality Board, Dr Shepherd reported that the Children’s

Mental Health Service did appear overall to be improving but there had been reports received that there were still issues of capacity within the service, particularly the drop-in clinics where children had been turned away from those clinics because there was not enough staff to see them. There had also been reports of capacity issues to respond in the appropriate timescales to urgent referrals.

16.14 Ms Clarke reported that the CQC was currently looking into these issues with Midlands Partnership

NHS Foundation Trust (MPFT) and there was a meeting planned that Steve Trenchard would be attending to discuss the over 25 service and the issues known in relation to Shropshire patients.

RESOLVE: THE GOVERNING BODY RECEIVED and NOTED the content of the Provider Quality

Exception Report. ACTION Ms Clarke and Dr Sokolov to share with the Governing Body the structured approach

taken to escalation of areas of concern. Minute No. GB-2019-03.045 – Operational Plan & Performance 17.1 Mrs Skidmore and Dr Davies gave a joint verbal update on the Operational Plan and Performance. 17.2 Mrs Skidmore explained that normally the Governing Body would be asked to sign off the budget for

next year; however, the CCG was currently working through its planning for the new financial year and was still deep in contract negotiations. At present, the plan for next year did not fully meet the CCG’s control total and the CCG, together with the support of the Finance and Performance Committee, was actively reviewing that and discussions were on-going with NHSE. Members were assured that there was a plan in place and this did not stop conversations taking place about the contracts for next year. There would be a paper presented to the next Governing Body meeting in May and if there were any updates on this in the meantime the Governing Body Members would be briefed.



17.3 Dr Davies similarly reported that work on the Operational Plan was on-going. Feedback had been

received from NHSE on the CCG’s plans and these were currently being worked through. A meeting was scheduled to take place on Friday where the plans would be discussed in more detail. This year, it was the first time the plans were being reviewed at an STP level so there was much more triangulation with individual plans to ensure there were no differences and that they were supporting the same priorities. Dr Davies reported that there had been a significant improvement this year in that for the first time all system partners had been present on the planning calls and there had been much more coordination and alignment of those plans.

ACTION: Mrs Skidmore to bring back an update on the 2019/20 to the next Governing Body meeting in May. Dr Davies to present the Operational Plans to the May meeting.

RESOLVE: THE GOVERNING BODY NOTED the contents of the verbal report on the Operational Plan

Performance. Minute No. GB-2019-03.046 – EU Exit Preparedness 18.1 Mrs Tilley reported that this item had been included in order to confirm to the Governing Body that the

CCG had fulfilled all the NHSE assurance requirements in readiness for the EU Exit preparation, which included areas such as working with staff who were EU nationals, reviewing business continuity plans and monitoring the supply of medicines.

RESOLVE: THE GOVERNING BODY RECEIVED the verbal update on EU Exit Preparedness.

Governance

Minute No. GB-2019-03.047 – Workforce Report (incorporating NHS WRES) 19.1 Workforce - Mrs Tilley referred to the headlines contained in the Workforce Report and reported that

there had been a small but steady increase in staffing numbers. The turnover remained in line with all NHS organisations within the region. As seen in the last report, sickness absence remained higher than target and the Directors were continuing to monitor sickness levels, particularly those related to stress and anxiety, which represented the largest causes of sickness in the organisation. The outcome of the Staff Survey highlighted that focus was needed on staff appraisals and protecting 1:1 time with managers and the directors had taken that action forward with a view to all appraisals being completed by the end of March where possible. Themes emerging form the appraisals would then be looked at and steps would be taken to support staff. In addition, mandatory training levels had improved but there was still room for further improvement and this would be monitored.

19.2 Mr Hutton referred to the report stating that stress was one of the biggest causes of sickness in the

CCG. Given the increasing cost pressures and the move towards a single commissioning body and potential impact that would have on all staff, in addition to monitoring the levels of sickness, Mr Hutton asked if the CCG was planning any measures that would reduce the impact that would have on staff.

19.3 It was confirmed conversations had been held with HR about how the CCG could support staff around

the day-to-day matters and the transition work going forward. The CCG would be looking to put a programme of organisational development in place. The staff survey was part of moving forward with a robust organisational development plan but this now needed to be linked with any work undertaken on working more closely with Telford & Wrekin CCG. It was planned to bring back a paper on organisational development to a future Governing Body Development session. It was further confirmed that the future reconfiguration of a single commissioner had been mentioned in staff briefings and staff were aware of the long term plan that the CCG needs to be part of an ICS by 2021.

19.4 NHS Workforce Race Equality Standard (WRES) – Ms Clarke explained that in 2014, the Equality and

Diversity Council agreed an action to ensure employees from black and minority ethnic (BME) backgrounds would have equal access to career opportunities and receive fair treatment in the workplace. It was vitally important that the CCG had a workforce that was valued. The WRES was a requirement for NHS commissioners and providers, including the independent organisations through the NHS standard contract. There was a link to the 2018 national WRES data report within the paper that compared data with previous years. The provider BME was less than the national average but it had been recognised that there was more work to be done. The providers’ action plans were available on their own websites and the links were contained in the paper. There was focussed work not only for the BME community but all operational development across all of the providers for all staff that they are valued and that the retention had improved and there were great opportunities going forward. The



Board noted that the CCG did monitor this through the CQRMs with the providers and would monitor the implementation of the action plan.

RESOLVE: THE GOVERNING BODY NOTED the content of the Workforce Report, which incorporated

the provider NHS Workforce Race Equality Standard Implementation. Minute No. GB-2019-03.048 – Audit Committee – 27 February 20.1 Mr Hutton read through his summary report presented, which highlighted the key points from the 27

February Audit Committee meeting, and the Governing Body were asked to agree the actions. 21.2 Dr Freeman said he agreed with the comment made on the agency workers and understood the issue

was with continuation. The Governing Body was advised that sometimes the process for submitting businesses cases to NHSE did take some time to be agreed. On the issue of the waiver, it was understood the CCG had been instructed to use Deloittes by NHSE. Mrs Skidmore further explained that there had been a national programme for a support partner in QIPP across all CCGs and NHSE had invited the CCG to take part in the wave 4 QIPP programme.

21.3 In response to the point made about CHC, Ms Clarke offered a positive note about the Complex Care

Team, which was a hugely difficult area of work. CHC and complex care were being separated with clear roles and responsibilities and proper administration support for each process. It was highlighted that in 2017 there was 0% on the quality premium for 28 day turnaround of decisions which was now 98%. This was as a result of work carried out by the CHC Team with the local authority and with the families of the individuals to ensure the process was streamlined.

21.4 Mr Hutton reflected on his time as Chair of the Audit Committee and reminded the Governing Body

that there had been instances identified in the internal audits where there had been failures in the CCG not following the due process. The advice given to the CCG was to perhaps focus better on getting the right processes in place and adhere to those in all cases.

RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the contents of the summary report

presented from the 27 February Audit Committee meeting and AGREED the following actions:

To put in place tighter controls with the CCG to ensure full compliance with NHSE approval processes for Agency Staff.

To consider using the Finance & Performance Committee to monitor spend and delivery of the Better Care Fund (BCF) contract.

To consider how to tighten up on the use of waivers for procurement and provide more detailed information to the Audit Committee to justify where they have been used.

To consider alternative approaches to managing CHC. Minute No. GB-2019-03.049 – Future Fit Joint Committee – 29 January 2019 21.1 The minutes of the Future Fit Joint Committee meeting held on 29 January 2019 were approved as an

accurate of the meeting. 22.2 Mr Shepherd asked for it to be noted that no members of the Shropshire Patient Group had taken part

in the disruption which had ensued from some members of the public attending the Future Fit Joint Committee meeting on 29 January.

FOR INFORMATION ONLY/EXCEPTION REPORTING Minute Nos. GB-2019-03.050 to GB-2019-03.055 22.1 The following minutes of the Governing Body Committees were received and noted for information

only:

Clinical Commissioning Committee – 19 December 2018 & 16 January 2019

Finance & Performance Committee – 5 December 2018 & 2 January 2019

Primary Care Commissioning Committee – 5 December 2018 & 2 January 2019

Quality Committee – 30 January 2019

A&E Delivery Group – 8 February 2019

South Locality Board – 3 January & 6 February 2019

Shrewsbury & Atcham Locality Board – 18 October 2018 & 17 January 2019

North Locality Board – 25 October 2018 & 24 January 2019 22.2 There were no points raised in relation to the minutes.



RESOLVE: THE GOVERNING BODY RECEIVED AND NOTED the minutes as presented above. Minute No. GB-2019-03.056 – Any Other Business 23.1 There were no items of any other business raised. DATE OF NEXT MEETING The next scheduled meeting of the CCG Governing Body is:

CCG Governing Body Meeting (open to the public) Wednesday 8 May 2019, 1pm, Shropshire Meeting Room 1, The MacDonald Hill Valley Hotel, Tarporley Road, Whitchurch, Shropshire, SY13 4HA.

SIGNED ………………………………………………….. DATE …………………………………………


ACTIONS FROM THE CLINICAL COMMISSIONING GROUP (CCG) GOVERNING BODY MEETING – 13 MARCH 2019

Agenda Item Action Required By Whom By When Date Completed/ Comments

GB-2019-03.033 – Minutes of Previous meeting

Mrs Tilley and Mrs Stackhouse to review the minutes for minor amendments. Mrs Stackhouse to action the amendments as agreed in paragraph 5.1.

Mrs Sam Tilley / Mrs Sandra Stackhouse

As soon as possible

Complete

GB-2019-03.034 – Matters Arising GB-2018-11.287 – Questions from Members of the Public GB-2019-01.008 – Commissioning Landscape GB-2019-01.33 – Finance and Contracting Report GB-2019-01.018 – Cancer Services Update GB-2019-01.019 – Shropshire CCG Staff Survey

Ms Clarke to forward to Mrs Bickerton the statement received from SaTH in response to Mrs Bickerton’s comments about food wastage. Mrs Tilley to produce a paper setting out the process for the integration of the two CCGs towards a single strategic commissioning organisation. Mrs Skidmore to update the Governing Body on the monitoring of activity reports carried out internally in the baseline work which would be available at the end of Qtr 1. Ms Clarke to look into the request relating to patient care issues as raised by a member of the public. Mrs Tilley to report back to the Governing Body feedback collated following staff appraisals and 1:1 meetings undertaken.

Ms Dawn Clarke Mrs Sam Tilley Mrs Claire Skidmore Ms Dawn Clarke Mrs Sam Tilley

As soon as possible May meeting 30 June 2019 for August meeting As soon as possible Future meeting

Complete Included on the agenda Complete

Agenda Item Action Required By Whom By When Date Completed/ Comments

GB-2019-03.035 – Questions from Members of the Public

Mrs Stackhouse to organise answers to be sent to the respondents.

Mrs Sandra Stackhouse

As soon as possible

Complete

GB-2019-03.037 – Governing Body Assurance Framework

Mrs Tilley to make the following amendments to the GBAF: Remove Risk 9: Directions Risk 4: Transformation – amend to reflect the Alliance Agreement had now been signed.

Mrs Sam Tilley

As soon as possible

GB-2019-03.040 – Transforming Care Programme (TCP)

Ms Clarke to bring back the outcome of the Learning Disabilities Mortality Review (LeDeR) to the next Governing Body meeting.

Ms Dawn Clarke

May meeting

GB-2019-03.042 – Finance, Contracting & QIPP (Quality, Innovation, Productivity & Prevention) Report

Dr Davies and Mrs Fortes-Mayer to bring back a more in-depth analysis of the system wide ambulance service review. Mrs Skidmore to bring back the 2019/20 Plan and budget to the next meeting.

Dr Julie Davies / Mrs Gail Fortes-Mayer Mrs Claire Skidmore

May meeting May meeting

Included on the agenda Included on the agenda

GB-2019-03.044 – Provider Quality Exception Report

Ms Clarke with Dr Sokolov to share with the Governing Body the structured approach taken to escalation of areas of concern.

Ms Dawn Clarke / Dr Jessica Sokolov

As soon as possible

GB-2019-03.045 – Operational Plan and Performance

Mrs Fortes-Mayer to present the Operational Plans to the May meeting.

Mrs Gail Fortes-Mayer

May meeting

Included on the agenda

Submitted Questions by Members of the Public for the Shropshire CCG Governing Body meeting 13 March 2019

Page 1 of 6

Submitted Questions by Members of the Public for the Governing Body meeting 13 March 2019

Name Submitted Questions CCG Summary Response

Chris Deaves I note that the “Ludlow and Surrounding Area Place Plan 2019/20” published recently by Shropshire Council Planning Policy Department lists a project described as: “Ludlow Health Facility – co-locate Ludlow Hospital, GPs, and other health services on one site to serve South Shropshire. (Ludlow)” with the accompanying note: “The CCG will discuss requirements in the area as part of the Estates Review, which is currently under development.” Will this CCG please describe what discussions they have conducted with Shropshire Council in connection with this proposal in the Place Plan and how they relate to other CCG strategic intentions?

The CCG has been working with Shropshire Council around the development of practices in Whitchurch and Shrewsbury Town Centre. Many practices are built using third party capital with the CCG paying rent on behalf of the practice. Our discussions with the council have been about them funding the capital element and therefore receiving the rent income into the council from the CCG. There have been no specific discussions around Ludlow or indeed anywhere else other than those identified above. Dr Simon Freeman

Ron Berry 1. Key information on our local NHS is withheld from the public and important decisions are increasingly taken behind closed doors. a. Will the Governing Body ensure publication of the draft Aggregate system operating plan, submitted to NHSE and NHSI on 19 February? b. Will the Governing Body ensure publication of the system Estates Workbook? c. Will the Governing Body encourage the inclusion of system-wide financial information in the STP made available to the public? d. Will the Governing Body's representatives on the STP Partnership Board and other STP-related workstreams argue for these meetings to be held in public and to produce publicly-available minutes? Will you support meetings in public and publicly-available minutes as the STP transitions to an ICS? 2. Does the CCG have any involvement with Shropshire Council’s local ‘Place Plans’?

We are not aware of key CCG information being withheld from the public. Nor are important CCG decisions taking place behind closed doors. The questions on publication of STP documents should be directed to the STP Chair. The CCG would support appropriate transparency of these documents and concur that the STP Partnership Board should be a meeting held in public. Dr Simon Freeman


Page 2 of 6

Jane Asterley-Berry On 25th February, I attended the ‘Care Closer to Home’ engagement event in the Shrewsbury Darwin centre. A few concerns arise from this: This felt very much like a tick box exercise: not publicised, in a remote corner, and inaccessible to most target users of new services.

The two staff present gave inaccurate information, at odds with CCG financial statements and the ‘Overview’ document on care Closer to Home. In particular they asserted there were no target cost savings to be achieved in community services and no reduction in existing community services to pay for new services targeted at older frail patients. They were adamant about this until CCG documents were shown and read to them.

The answer to many of our questions was “It’s not for sharing” or “That’s not in the public domain”. This is not a transparent approach.

a) 1. Will the Governing Body ensure that accurate information is given to the public at engagement events? Do you agree giving incorrect information invalidates engagement?

b) 2. The Patient Group representative resigned in October 2018; the Patient Group nominee for a replacement was rejected by the CCG; and the CCG put in place its own process to enable selection of a patient representative (selected late last month). Has there been a policy change, that the Patient Group no longer provides patient representation to workstreams? What mechanism is in place to ensure that the newly appointed patient representative is representative of and accountable to patients? Will they report back? Meet with patients? How can I contact them?

c) 3. Will the CCG now involve the wider public – urgently and meaningfully – in the development of Phase 3 Care Closer to Home plans for their own localities? There is a wealth of expertise in our communities, and people are being excluded from shaping the services they and their families and friends will use. This has been asked for many times. (20 pre-selected people allowed to attend occasional central stake holder events is no substitute for detailed co-design at local level).

d) 4. We know drafts of proposed Phase 3 services were completed 3 months ago. Can those now be shared with the public?

e) 5. The two staff members were unable to answer many questions, and offered to set up a meeting with me and the two other members of the public with me. They offered to include other CCG representatives who might be able to deal with those areas. We welcomed this and left our emails, but we have heard nothing. Can this be taken forward?

The event was a ‘What Matters to Me’ event; this is a national NHS engagement event. The event is designed to ask members of the public what matters to them about their health and social care services in their local communities. The event was not part of the Shropshire Care Closer to Home (SCCtH) engagement strategy and was not an event aimed at answering questions from members of the public on CCG business and strategy development.

• On 27th

March at the Trinity Centre in Shrewsbury there is a public engagement event focusing solely on SCCtH. At this event the development of Phase 3 models will be facilitated with over 100 delegates from across Shropshire.

• • The patient representative for the SCCtH

programme was appointed following an open recruitment process to ensure that all those people interested had the opportunity to apply.

• • With regard to the request for the meeting. The

commissioning and clinical leads for the SCCtH programme will be happy to meet the individuals concerned regarding the SCCtH programme. Dr Julie Davies


Page 3 of 6

Pete Gillard 1. Shropdoc recently assured the Daily Mail that after midnight there was one GP on duty for Shropshire, Telford and Wrekin, in addition to the triage GP. A spokesperson for Shropshire CCG, Telford and Wrekin CCG, ShropComm and Shropdoc subsequently told the Shropshire Star that there were two GPs on duty. Can the CCG clarify? Is the second GP the triage GP who answers calls for Shropshire, Telford and Wrekin and Powys; who in many cases works from home; and would seldom have face to face contact with patients? Or are there two GPs for face to face patient contact in addition to the triage GP? 2. When is the review of the new Shropdoc GP Out of Hours service due to take place? This was due I believe around 6 months from the start of the new contract on 1st October. I note the absence of public consultation on the initial very substantial changes to the service. Will the CCG ensure public input into the review? What form will that involvement take? Does the CCG believe that S14Z2 of the NHS Act 2006 applies to its changes to Shropdoc, and if not, why not?

3. The CCG will be implementing substantial QIPP savings in the coming financial year. The CCG is covered by S14Z2 of the NHS Act and has a statutory duty to involve the public in the development and consideration of proposals for changes which, if implemented, would have an impact on services.

3.Will the CCG commit to publishing its proposed QIPP plans, including the anticipated changes to services, and ensure engagement/consultation in line with this duty before finalising its QIPP plans? Will the CCG ensure meaningful public involvement of service users and the wider public before progressing QIPP savings that will have an impact on services?

1. After midnight in Shropshire, home visits are covered by 1 GP based in Telford and 2 Urgent Care Practitioners (UCPs) supported by another 1 GP based at Shropdoc's HQ who provides telephone advice to patients identified by 111 as needing assessment and advice to the UCPs on home visits. Additionally, each night there is a UCP District Nurse or Relief care operating until 0100. Shropdoc provides OOH care to the population of Powys; so the triage GP identified above also answers calls passed by the 111 service in Wales. Mrs Gail Fortes-Mayer 2. The lead commissioner for the Shropshire Community Health Trust out of hours contract is Telford and Wrekin CCG and they will be undertaking the review. Dr Simon Freeman 3. The CCG QIPP schemes are composed of the major service delivery changes on which we have been involved and engaged in a meaningful way. Any substantial service change would of course require prior public consultation. Dr Simon Freeman


Page 4 of 6

Gill George 1. The QIPP Update report notes a requirement for QIPP savings of between 5.9% and 6.9%. Does any Governing Body member believe QIPP savings of that extent are achievable without a significantly detrimental impact on patient care? 2. I understand that the STP identifies a system-wide potential financial gap of £50 million to be addressed in 2019/20. Currently Shropshire CCG’s QIPP value within the SaTH contract is £6.3m, well over the £2.6m assumed value of surplus to be achieved by SaTH through Future Fit. SaTH has also dropped its assumptions of repatriation income from an initial £12m a year to zero. Was the CCG aware of the £50 million gap and of your own QIPP targets for SaTH prior to the Joint Committee on 29th January? Were you aware of SaTH’s revised assumptions around repatriation? Why were these matters not raised by CCG representatives at the Joint Committee?

The CCG representatives on the Joint Committee supported the recommendation ‘Reconfirming affordability, including the patient flow assumptions since the PCBC was approved; noting that further refinement will be included within the Outline Business Case (OBC) which is expected for approval in July 2019’. On what basis did the CCG decide this sharply changed financial situation did not greatly affect Future Fit affordability, and that changes could be dealt with through ‘refinement’? 3. Patient demand for non-elective care has continued to increase. It was reported to the 7th February SaTH Board meeting that there was a 13.2% increase in A&E attendances comparing January 2018 to January 2019, and a 17% increase in patients arriving by ambulance. (SaTH attributes much of this increase to Shropdoc changes). Your own papers for this meeting note that for Shropshire patients, emergency admissions are over-performing by 5.1% above plan, and A&E attendances are over plan by 7.9%. Was the CCG aware of the significant increases in non-elective activity

1. The Governing Body would not agree to any productivity or savings plan without a Quality Impact Assessment, confirming that the plan did not have a detrimental impact on patient outcomes. Every project is therefore considered on its own merits. Dr Simon Freeman 2. The decision at the Future Fit Joint Committee on the 29thJanuary was based on the affordability detailed in the Decision Making Business Case (DMBC). Since that date allocations for CCGs and business rules have now been published. The affordability of Future Fit will continue to be addressed in future stages of approval taking into account any changes to assumptions or finances that have become apparent since 29th January. Dr Simon Freeman 3. While there has been a significant rise in non-elective admissions at SATH the vast majority of this has been zero day length of stay. A&E attendance growth has been in line with that seen elsewhere nationally. Any required changes to activity modelling will need to be addressed in the subsequent approval in the stages of the Future Fit


Page 5 of 6

before the Future Fit Joint Committee on 29th January? This is of obvious relevance to Future Fit modelling of future capacity. Why was this not raised by CCG representatives at the Joint Committee? The recommendation supported by CCG representatives, was ‘reconfirming affordability including the patient flow assumptions’. Is the CCG confident that the activity levels and bed and staff numbers modelled in Future Fit remain valid? Can changes to demand of this magnitude be dealt with through ‘refinement’? Is there a risk of an Emergency Centre that cannot meet future patient demand unless fundamental remodelling of Future Fit assumptions takes place?

4. The CCG’s constitution requires Board papers to be publicly available 5 days before the meeting. The ‘Code of Practice on Openness in the NHS’ requires Board papers to be publicly available 7 days in advance. The CCG made papers for this meeting available after the close of the working day on Friday, after prompting, despite a deadline for public questions of Monday lunchtime. What steps is the CCG taking to ensure future timely publication?

5. Has the CCG undertaken an EIA of its decision to hold Board meetings in a variety of locations around the county, given the potential impact on people with disabilities or older people who wish to attend but face more challenging journeys? Will the CCG publish its EIA report? If no EIA has taken place, will the CCG undertake one?

business cases. Dr Simon Freeman 4. The CCG’s Constitution does require publication five days in advance. We apologise that on this occasion this was not met. Going forward this issue will not recur. Dr Simon Freeman 5. The CCG is committed to allowing all members of the public to access Governing Body meetings. Our view is that this is enabled by holding meetings in a number of places. We would point out that every meeting is live streamed ensuring the whole population of the county has access to every meeting. Dr Simon Freeman

Marilyn Gaunt 1. It was reported to the Shropshire HOSC of 21st January that the CCG is ending its small subsidy – said at the meeting to be £24,000 – to community transport schemes that support Shropshire people in attending medical appointments. (This is at the same time as a cost-saving review of non-emergency patient transport, and councillors were clear that it is becoming increasingly difficult for patients to access the transport they need to reach healthcare appointments). Is it the case that the CCG funding to community transport has ended? If so, did the CCG carry out an Equalities Impact Assessment, and will you

1. We are not aware of any reduction in CCG support to patients eligible for community transport to access hospital appointments. All investments made by the CCG will of course be subject to annual scrutiny to ensure value for money.

Mrs Gail Fortes-Mayer


Page 6 of 6

share this? Did the CCG consult on its plans, given the potential impact on vulnerable people in our community? 2. As a Ludlow resident, I recently wanted to use Hereford Hospital for my healthcare as I prefer Hereford Hospital to Shrewsbury. My GP told me that I could not, and I reluctantly had my care at the Royal Shrewsbury. I have spoken to another Ludlow resident who was told by the CCG’s Referral Assessment Service that he had to use SaTH despite his strong preference being to use Hereford Hospital where he has been treated for a decade. Can the CCG reassure me that it has made no attempt to restrict patient choice? This would be against the NHS constitution.

3. The Frailty Front Door service is a positive initiative. However, we note that a recent media release spoke of social care follow up within 48 hours. It remains very unclear what happens to an older person where admission is avoided. How long do they wait for patient transport home? Are they left e.g. in a cold house with no support, perhaps distressed and confused? What follow up is available in the community and with what timescale? What evaluation is taking place of patient experience and patient outcomes, rather than avoided admissions alone?

2. The CCG absolutely supports the constitutional right of choice and the RAS was set up to help support patients with more informed choice e.g appointment availability and relative waits of all local and out of area providers. We are happy to discuss the specific issues raised with the individuals concerned. Dr Julie Davies

3. All patients who are discharged direct from ED by the Frailty Team undergo a thorough assessment of their needs both clinical and social to ensure a safe discharge. Where domiciliary care or other support at home is required this is secured before the patient is discharged including referrals for follow up by other community services.

In order to capture the whole patient experience, the CCG is working with the relevant service providers in the community to capture feedback on patient experiences post discharge. Dr Julie Davies

1

Governing Body – 08.05.19 Agenda Item GB-2019-05.063

Title of the report:

Transforming Care Report (TCP)

Responsible Director:

Dawn Clarke, Director of Nursing, Quality and Patient Safety

Author of the report:


Presenter:


Purpose of the report:

This report is to provide the Governing Body with an update in relation to the plans of the Shropshire Transforming Care Partnership footprint in order to take forward the national agenda to reduce in patient bed usage for people with learning disabilities.

The high level summary of the key issues is submitted to the Governing Body for assurance purposes and to ensure that the Governing Body is aware of the areas that require attention.

Key issues or points to note:

A multi-agency approach to avoiding unnecessary hospital admission is working effectively for the adult individuals requiring additional support. This has been acknowledged by NHS England. Further work is required to strengthen admission avoidance for children and young people and membership of the group is being strengthened. This links to the Strategic 0-25 Development Plan.

There were no discharges to the community in 2018/19 despite efforts to expedite safe discharges. It was anticipated that four patients would be safely discharged before the end of March 2019 but just one was discharged in mid April with a further three discharge dates planned for June. This is below trajectory and has been due to the patient continuing to require active treatment or delays with the property works and/or provider recruitment issues. No delays have occurred due to community Learning Disability health provision not being available. NHS England funding of £30k has been used to expedite discharge where safely possible.

A meeting is being convened to review the NHS England placed patients to better understand their current care and discharge status and what can be done to move things forward.

The TCP Board meets monthly. STP arrangements are currently being revised and there is agreement that a sub group is established below the STP Mental Health Board, chaired by someone with appropriate expertise in the needs of people with LD. This individual would in turn sit on the STP MH Board to ensure the voice of people with LD is heard at system level. The STP Programme Director for Mental Health is to attend the forthcoming TCP Board to discuss some of the ongoing work, priorities and potential transfer of governance to ensure safe handover of responsibilities and structures. The TCP Programme Board will continue until satisfactory governance arrangements are in place.

NHS England recently commended the TCP on its implementation of Care and Treatment Reviews (CTR) evidenced as part of an audit of effectiveness undertaken in November 2018. A further audit of CETR in children and young people is being undertaken with a report to TCP

2

Board expected in June or July 2019.

A Multidisciplinary review of a patient death was convened as part of the Learning Disabilities Mortality review (LeDeR) Programme. The outcome will be reported on in due course but initial findings have confirmed the individual received good care from the GP and during the acute hospital admission with the appropriate investigations and treatment taking place.

A comprehensive Workforce Plan has been developed and submitted to NHS England and is aligned to STP workforce planning priorities. It aims to develop skilled staff who understand TCP shared values and who can provide the level of service required.

In April, the Shropshire TCP Community Services self -assessment was submitted to NHS England. The return acknowledges that further investment is required to support the Intensive Support Team function in Children and Young People’s (CYP) services as the present service in CYP crisis is to provide generic support rather than behavioural support

Actions required by Governing Body Members: For the Governing Body to receive the report and to note the challenge in relation to the discharge planning of the CCG individuals and the challenges highlighted in the provision of Children and Young People’s Services. More detailed reports are considered at the Shropshire TCP Programme Board..

3

Monitoring form Governing Body 08 May 2019

Agenda Item: 2019-05.063

Does this report and its recommendations have implications and impact with regard to the following:

1 Additional staffing or financial resource implications Yes If yes, please provide details of additional resources required

Yes – the TCP team have been recruited. Forensic team to be agreed.

2 Health inequalities Yes If yes, please provide details of the effect upon health inequalities

This work is focused on a vulnerable group with disabilities and who have significant health inequalities, the aim of the TCP agenda is to reduce the health inequalities for this cohort group.

3 Human Rights, equality and diversity requirements Yes If yes, please provide details of the effect upon these requirements

Equality and equity by each organisation is implicit as part of the transforming care processes. Commissioning for quality, safety and a good patient experience for people with learning disabilities and their families is paramount to the development of the plan and future model.

4 Clinical engagement Yes If yes, please provide details of the clinical engagement

Providers, partners and all key stakeholders are actively involved within the TCP work streams and consultation and engagement events held in relation to all future developments.

5 Patient and public engagement Yes If yes, please provide details of the patient and public engagement

Co-production will continue throughout developments of the model with children & young people, adults – their families and carers.

6 Risk to financial and clinical sustainability Yes If yes how will this be mitigated

There is potential of significant cost pressures to the CCG’s and Local Authorities as patients in secure settings are repatriated back into county. The TCP is working closely with NHSE to ensure monies flow down as the patients are transferred; the processes for this happening continually changes.

Agenda item: GB-2019-05.064 Shropshire CCG Governing Body meeting: 8.05.19

Title of the report: Finance and Contracts Report to 31st March 2019

Responsible Director: Claire Skidmore – Chief Finance Officer

Author of the report: Laura Clare - Deputy Chief Finance Officer Meryl Flaherty – Head of Contracting

Presenter: Claire Skidmore – Chief Finance Officer

Purpose of the report: The purpose of this report is to articulate the finance and contracts position, and to highlight any risks.

Key issues or points to note at 31st March (Month 12):

Finance • At Month 12 the CCG has reported that it missed the 2018/19 control total by £5.1m.

• Our initial control total for the year was a deficit of £13.3m. The additional £5.1m

expenditure results in an overall deficit of £18.4m offset by Q1 achievement of CSF of

£1.3m. The CCG is therefore showing an in year deficit of £17.1m.

• This compares with a deficit in 2017/18 of £27m relative to a control total of £19m.

• At Month 12 the CCG is reporting an underlying/recurrent deficit of £28.7m.

Contracts • The CCG has agreed a year-end position for both SaTH and RJAH for 2018/19

• The contract with Betsi Cadwaladr for 2018/19 has been escalated to NHSE for

arbitration. The CCG is awaiting confirmation of next steps.

• No 2019/20 contracts are being escalated to mediation/arbitration and all main contracts

have now been signed.

Actions required by Governing Body Members: The Committee is asked to:

o Note the content of this report


1 Additional staffing or financial resource implications No If yes, please provide details of additional resources required

Note the additional resource provided under the ISA with NHS England.

2 Health inequalities No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements No If yes, please provide details of the effect upon these requirements

4 Clinical engagement No If yes, please provide details of the clinical engagement

5 Patient and public engagement No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes If yes how will this be mitigated

Un-mitigated risk signals that, if risks were to materialise, the CCG would not have sufficient financial cover to offset these. The fragility of the CCG’s finances should not be underestimated. Although the Month 12 position is now reported, risks still exist moving into 2019/20.

Below is a list of schedules appended to this report.

Appendix Content Appendix 1 Detailed income and expenditure information

Appendix 2 Statement of Financial Position

NHS Shropshire CCG

Governing Body Meeting- 8th May 2019

Finance and Contracts Report to 31st March 2019

Executive Summary and Actions Required

1. The purpose of this report is to articulate the key elements of our finance and

contract positions, and to highlight any areas of risk within the reported position.

2. The CCG was given a control total of £13.3m deficit in 2018/19 (though

Commissioner Sustainability Funding (CSF) could have been earned up to this

level). The CCG was also expected to meet all CCG ‘business rules’ (except for

achieving a surplus of 1%).

3. The CCG received £1.33m, after qualifying for CSF in Q1. The CCG did not qualify

for any further instalments.

4. CSF earned to date revised the in-year deficit to £17.06m as per NHS England

guidance.

Month 12 finance position

5. We are reporting at Month 12 that we are off-plan by £5.1m

6. At Month 12 the CCG is reporting an underlying deficit of £28.7m as non recurrent

benefits received in year have offset recurrent overspends.

7. The main factors contributing to our overall position are volatility in CHC/Complex

Care, over-performance in our major acute contracts and under-delivery in our QIPP

programme.

8. The CCG agreed a year-end deal with both SATH and RJAH

9. Risk remains around the contract with Betsi Cadwaladr University Health Board and

has resulted in NHSE being requested to arbitrate.

10. The CCG continues to manage liabilities and assets: and all of the Better Payment

Practice Code (BPPC) targets were achieved. (> 95%.)

11. The CCG managed cash within target for the year.

Month 12 Contract position

12. Year end agreements were made with SATH and RJAH. The majority of other

providers have had year end values agreed through the agreement of balances

exercise.

13. 2019/20 contracts with main providers have been agreed and signed.

Performance dashboard

14. Our overall dashboard for Month 12 is as follows:

Target/ Duty Target RAG

Control Total Deficit £13.3m R

CSF earned £13.3m Q1: earned (£1.330m) Q2: did not earn Q3: did not earn Q4: did not earn

Cash 1.25% monthly drawdown

G

Better Payment Practice

>=95% G

2019/20 Financial Plan

15. The 2019/20 financial plan is the subject of a separate paper on this agenda. .

Actions Required:

The Committee is asked to:

Note the content of this report

Overall Financial Position

16. The table below summarises the budget and actual position for the full

financial year.

17. Our reported financial position is consistent with the ledger.

18. Further detail of expenditure by area is included at Appendix 1.

Allocations 19. In-month the CCG received additional net allocations of £0.100m. £0.547m

was transferred to Telford CCG in relation to their proportion of mental health

allocations. Other notable adjustments included £285k additional allocation for

drugs (NCSOs), and £250k for QIPP support.

Expenditure

20. The CCG finished the year £5.1m away from the expenditure plan, mainly due

to volatility within CHC/Complex Care, over-performance within Acute areas

and QIPP slippage.

Underlying Financial Position

21. We are reporting an underlying deficit of £28.7m. Our underlying position is masked

in the overall position by our use of non-recurring support and the use of available

reserves and contingencies.

Expenditure

Acute Services

22. The following summarises contract positions at Month 12, using the most

recently available activity data (one month in arrears to Month 11).

Budget Year

to Date -

Month 12

Actual Year

to Date -

Month 12

Variance Year

to Date -

Month 12

Annual Budget

£000 £000 £000 £000

Revenue Resource Limit

Recurrent Allocations 403,371 403,371 0 401,642

Non Recurrent Allocation 8,644 8,644 0 10,373

Deficit Brought Forward (59,667) (59,667) 0 (59,667)

Co-Commissioning Allocation 43,033 43,033 0 43,033

Total resource limit 395,381 395,381 0 395,381

EXPENDITURE

Commissioning 402,682 419,020 16,338 402,682

Corporate 4,895 4,412 (483) 4,895

Reserves 9,513 (1,276) (10,789) 9,513

Healthcare Sub Total 417,090 422,156 5,066 417,090

Running Costs 6,896 7,204 308 6,896

Co-Commissioning 43,033 42,747 (286) 43,033

Total Expenditure 467,019 472,107 5,089 467,019

(Surplus)/Deficit 71,638 76,726 5,089 71,638

Deficit Brought Forward (59,667) (59,667) (59,667)

In Year Deficit 11,970 17,059 5,089 11,970

2018/19

Note 1: The Shrewsbury and Telford Hospitals NHS Trust position includes Contract and Non Contract

values (tables reported elsewhere may reflect the contract position only)

Shrewsbury and Telford Hospitals Trust (SaTH) –£4.261m over-spend

23. Notwithstanding the year-end deal made with the Trust we continue to monitor

the on-going over-performance, in order to assess the impact on our planning

for 2019/20.

Notices

Notice Standard Update

Contract performance Notice

The percentage of A & E attendances where the Service User was admitted transferred or discharged within 4 hours of their arrival at an A&E department.

Continual review of performance is managed at the A&E Delivery Board. Current performance is 72.85% against a target of 95%.

Contract performance Notice (Cancer performance)

Cancer Performance

2 Week GP referral to

1st OP Appointment

62 days urgent referral

to treatment

Cancer continues to be an area of concern for the CCG. Currently the 2 week referral to appointment is 89.8% against a target of 93%. The 62 day urgent referral is 69.3% against a target of 85%. The Remedial action plan is fully discussed at the Planned Care Working Group.

2019/20

24. The 2019/20 contract negotiation meetings are now complete and the 2019/20

contract has been signed. The CCG PMO will be actively monitoring QIPPs both

through activity and action delivery from both providers and commissioners.

Robert Jones and Agnes Hunt NHS Foundation Trust - £1.733m over-spend

25. A weekly dashboard continues to monitor the performance of the MSK triage and

Assessment service (SOOS). The service is closely monitored at Planned Care

Working Group (PCWG). Also, the CCG has commenced an audit into patients that

are referred for treatment from one consultant to another without passing through the

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Shrewsbury and Telford Hospitals NHS Trust 138,624 138,624 142,886 4,261

Robert Jones and Agnes Hunt FT 32,367 32,367 34,100 1,733

West Midlands Ambulance Service Contract 12,276 12,276 13,421 1,145

Other Acute Contracts 25,690 25,690 28,041 2,351

Acute NCA's 4,622 4,622 4,281 (341)

Acute Special Placements 34 34 36 2

Winter Resilience 2,030 2,030 2,266 236

Future Fit 556 556 492 (64)

STP 480 480 443 (37)

Acute services - Other 60 60 105 45

High Cost Drugs 383 383 393 10

Acute Services Team 644 644 508 (136)

Acute Services Total 217,766 217,766 226,972 9,205

YTD Performance M12

Annual Budget £'000

CCGs Referral Assessment Service (RAS). The outcome of the audit will be

reported next month.

Notices


Contract performance Notices

Percentage of patients on incomplete non-emergency pathways waiting no more than 18 weeks.

The current trajectory target is to reach 92% by March 2019 Progress against the RAP and return to trajectory is being reviewed at the monthly PCWG.

2019/20

26. The CCG has worked closely with the Trust to model the changes and adjustments

required for the 2019/20 contract. This includes undertaking MSK comparator

analysis to benchmark Shropshire CCG against other similar sized CCGs.

Historically, the CCG’s MSK spend has been much higher than other comparable

CCGs and the CCG needed to ensure for 2019/20 this is brought down to average

levels. This has formed the basis of the £2.4M QIPP scheme that is contained in the

contract

West Midlands Ambulance Service –over-spend £1.145m

27. We have not significantly changed our FOT in month. We are still seeing

significant over-performance, with activity more than 7% higher than planned,

and have allowed for this in the position.

2019/20

28. 2.5% growth has been agreed in the 2019/20 contract. The main change to the

contract will be the currency the contract will be measured in. This will alter to

‘incidents with a disposal’ and the CCG will not pay for anything which has no

resource commitment.

Other Acute Contracts –over-spend £2.351m

29. There are three main drivers of the forecast over-performance:

Prior year cost pressures across the portfolio

Over-performance across several Trusts (Betsi, Dudley Group and Wye

Valley)

QIPP under-delivery.

Community Health Services

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Shropshire Community Trust 39,206 39,206 39,136 (70)

Other Community Services 4,109 4,109 3,801 (308)

Palliative Care 2,404 2,404 2,308 (96)

Childrens Special Placements 0 0 0 0

Community Health Services Total 45,719 45,719 45,245 (474)

YTD Performance M12


Community Health Services - £0.474m under-spend

30. The main area of underspend in the community section relates to out of area

providers and a small underspend on PBR at Shropshire Community Trust.

2019/20

31. Several service specifications will be reviewed in year and new specifications will be

added to the contract once agreed.

32. Contract Negotiations are now complete.There is a QIPP value of £350k within the

Community contract which is dependent on the Trust and CCG collectively

identifying QIPP schemes during Quarter 1 2019-20

Continuing Healthcare and Complex Care

Continuing Healthcare and Complex Care – YTD £6.874m over-spend

Note 1: We continue not to report a table of case numbers this month. Broadcare is currently unable to produce reliable tables of cases. The CHC team is considering how to address this.

33. There was a £0.426M increase compared to the forecast expenditure out-turn

produced in February, a summary of which is shown below.

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Complex Care 25,643 25,643 34,260 8,617

Funded Nursing Care 8,199 8,199 6,404 (1,795)

Complex Care Team 967 967 1,173 206

Reablement 735 735 581 (154)

Continuing Healthcare Total 35,544 35,544 42,418 6,874

YTD Performance M12


Mental Health Services

Mental Health Services –£0.63m under-spend

34. The key driver for the under-spend is a movement of funds totalling £600k

between Telford and SCCG as part of the collective rebasing of the Midlands

Partnership Trust (MPFT) contract.

35. Adverse YTD variances have arisen in NCAs, mainly due to high costs per

case with out of area NHS mental health providers and other high cost

invoices from providers.

36. The overall Mental Health position includes elements of Transforming Care

Partnership (“TCP”).

Notices


Contract performance Notices

Concerning the lack of performance in delivering the 0-25 Emotional Health and Well-being Service

The Trust is implementing an agreed RAP which is being closely monitored by Commissioners. The Intensive Support Team did an audit of the service in conjunction with Commissioners. The action plan from MPFT has been updated to respond to the recommendations from the IST and to provide a detailed project plan. Progress against the plan is monitored at the Contract Meetings. The key risks identified by the Trust are detailed on their risk register.

2019/20

36

Agency costs increases within Complex Care Team 38

Dom Care adjustment - March

621

114

140

259

477

72

118Retrospectives included in M11 now agreed not to be paid

Increase in Broadcare costs M11-M12

Transfer of continence prior yr benefit to Community

Change in Children's JF forecast

Credit notes and reimbursements

Transfer of costs re BC2409 to Community

Transfer of continence budget to Community

Total changes (Net £0.426M increase) 1186 760

Other 57

In month movementsCost

£K

Benefit

£KNew ratifications 14

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Midland Partnership FT 30,290 30,290 30,597 307

Other NHS Mental Health Contracts 169 169 (812) (981)

Mental Health NCA's 1,027 1,027 1,521 494

Mental Health Special Placements 0 0 0 0

Mental Health - Winter Resilience 0 0 0 0

Mental Health - Other 1,492 1,492 1,692 200

Mental Health - TCP 300 300 217 (83)

Mental Health Services Total 33,278 33,278 33,215 (63)


YTD Performance M12

37. CCGs must continue to increase investment in mental health services in line

with the Mental Health Investment Standard (MHIS). The CCG has an

increased target for patients entering treatment into the IAPT service to 22%

(from 19%) for 2019/20. All mandated Mental Health targets will be contained

within the contract.

Primary Care Services (Non-Delegated)

Primary Care Services – £0.062m under-spend:

Prescribing

38. The prescribing forecasts are based on information from the month 10 PMD

data with local adjustments. The forecast overspend in prescribing reflects a

prudent view on in-year price adjustments to category M and other in-year

price changes, despite anticipated QIPP savings from current schemes.

Finance continues to work closely with the CCG’s Head of Prescribing to

monitor any changes to the forecast position.

39. The current PMD forecast spend compared to last year’s outturn has reduced

by approximately 0.6%.

Other

Other –£0.377m over-spend

40. Other expenditure is over-spent for the full year. This is mainly due to the non-

delivery of Better Care Fund QIPP.

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Prescribing 47,204 47,204 48,112 908

Central Drugs 1,289 1,289 1,265 (24)

Oxygen 630 630 620 (10)

Enhanced Services 4,471 4,471 4,130 (341)

Out Of Hours 4,011 4,011 3,785 (226)

Primary Care Commissioning Schemes 1,433 1,433 1,580 147

Hospice Drugs 95 95 100 5

Prescribing Incentives 515 515 393 (122)

Care Home Advanced Scheme 206 206 260 54

Primary Care Team 1,877 1,877 1,508 (369)

Primary Care IT 945 945 861 (84)

Primary Care Services Total 62,676 62,676 62,614 (62)


YTD Performance M12

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Patient Transport 3,165 3,165 3,118 (47)

NHS 111 741 741 747 6

Referral Assessment Service Team 462 462 362 (100)

Community & Care Co-ordinators 370 370 370 0

NHS Property Services 210 210 263 53

Better Care Fund 6,666 6,666 7,779 1,113

Shropshire Intervention Framework 500 500 0 (500)

Other 480 480 332 (148)

Other Total 12,594 12,594 12,971 377


YTD Performance M12

41. The £500k Shropshire Intervention Framework under spend relates to the

inclusion of our ISA funding from NHS England within our programme area,

with associated costs reported in running costs.

42. Patient Transport costs include expenditure from a number of providers, Falck

being the major one.

43. The Commissioners to the Non-Emergency Patient Transport Service Contract

(Shropshire CCG, Telford and Wrekin CCG, The Robert Jones and Agnes

Hunt Orthopaedic Hospital NHS Foundation Trust) and Falck have agreed to

extend the current service provision past the contract expiry date of 31

October 2019 to 31 March 2020 whilst a full procurement exercise is

undertaken.

Primary Care (Delegated)

Primary Care Services - YTD £0.286m under spend

44. In-month actual under-spends were linked to Enhanced Services (Extended

Hours/Minor Surgery),as well as Premises savings linked to the release of a

prior year Rent accrual. These were partly offset by over-spends related to

Dispensing & Prescribing associated with an increase in charges in recent

months, Other GP Services (Locum charges) and the increased costs linked to

the Global sum.

Running Costs

YTD Performance M12

Annual Budget YTD Actual Variance Actual £000 £000 £000

Dispensing & Prescribing 2,325 2,368 43

Enhanced Services 946 649 (297)

General Practice APMS 1,197 1,204 7

General Practice GMS 27,484 28,194 710

General Practice PMS 365 354 (11)

Other GP Services 1,132 1,021 (111)

Premises Costs Reimbursements 5,155 4,709 (446)

QOF 4,515 4,248 (268)

0.50% Contingency 217 0 (217)

Reserves (304) 0 304Co Commissioning Total 43,033 42,747 (286)

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Corporate Costs 4,015 4,015 3,131 (884)

Service Planning 735 735 1,082 347

Commissioning & Contracting 626 626 467 (159)

Strategy & Service Redesign 358 359 312 (47)

Finance 694 694 1,937 1,243

Governance 283 283 119 (164)

Nursing & Quality 184 184 156 (28)

Running Cost Total 6,895 6,896 7,204 308


YTD Performance M12

Running Costs YTD £0.308m over-spend

45. Costs incurred under the Intervention and Support Agreement with NHS

England are being shown in Running Costs, whilst the associated funding of

£500k is shown within programme as requested by NHS England. This

accounts for the majority of the forecast over-spend.

Reserves

46. A summary of reserves is provided in the table above. Reserves and one-off SOFP

benefits have been fully utilised to offset cost pressures.

Statement of Financial Position (SoFP)

47. The SOFP (see Appendix 2) is prepared in accordance with International

Financial Reporting Standards (IFRS), HM Treasury’s Financial Reporting

Manual and Department of Health and Social Care requirements.

Cash – (£0.088m)

48. The CCG is required to estimate its cash requirement prior to the start of each

month and draw down cash funding. In line with guidance, the CCG must

ensure cash held at the bank at the end of the month remain below 1.25% of

the monthly draw-down.

49. Cash drawn down in the month was £36.2m and the actual bank balance at

the end of March was £88k which was 0.24% of the monthly draw-down, well

within the 1.25% target set by NHSE. An additional £3.5m was drawn-down

mid-month to meet additional payments which were uncertain at the time of

requisitioning the March cash. This additional draw-down does not form part

of the cash target calculation.

50. The difference of £3k between the actual cash held at the bank and the cash

balance on the SoFP relates to items not yet cleared through the bank account

at the month-end.

Better Payment Practice Code (BPPC) Statistics

51. The CCG met all 4 BPPC targets both in month and cumulatively for the

2018/19 financial year. We continue to work with Budget Managers and the

CSU to maintain this level of performance.

52. 98.2% of invoices were processed within the 30 day limit. 97.4% of NHS

invoices (representing 99.2% of invoice value) were paid within the limit and

98.3% of Non-NHS invoices (representing 98.3% of value) were also cleared

within the limit.

Ytd

Budget £'000

Ytd

Actual £'000

Variance £'000

o/(u)

Non-recurrent support in reserves 5,100 5,100 0 (5,100)

Other reserves 2,196 2,196 (1,276) (3,472)

0.5% Contingency 2,217 2,217 0 (2,217)

Reserves Total 9,513 9,513 (1,276) (10,789)


YTD Performance M12

Appendix 1

2018/19 Financial Summary Position as at Month 12

Recurrent Budget Non Recurrent BudgetAnnual

Budget

Budget Year to

Date - month 12

Actual Year to Date -

month 12

Variance Year

to Date -

month 12

£000 £000 £000 £000 £000 £000

RESOURCES

Recurrent Allocation 401,642 10,373 412,015 412,015 412,015 0

Deficit Brought Forward 0 (59,667) (59,667) (59,667) (59,667) 0

Co-Commissioning Allocation 43,348 (315) 43,033 43,033 43,033 0

Total resource limit 444,990 (49,609) 395,381 395,381 395,381 0

EXPENDITURE

Acute Services

Shrewsbury and Telford Hospitals NHS Trust 138,624 0 138,624 138,624 142,885 4,261

Robert Jones and Agnes Hunt FT 32,367 0 32,367 32,367 34,100 1,733

West Midlands Ambulance Service Contract 12,087 189 12,276 12,276 13,421 1,145

Other Acute Contracts 25,690 0 25,690 25,690 28,041 2,351

Acute NCA's 4,622 0 4,622 4,622 4,281 (341)

Acute Special Placements 34 0 34 34 36 2

Winter Resilience 2,030 0 2,030 2,030 2,266 236

Future Fit 261 295 556 556 492 (64)

STP 175 305 480 480 443 (37)

Acute services - Other 60 0 60 60 105 45

High Cost Drugs 383 0 383 383 393 10

Acute Services Team 579 65 644 644 508 (136)

Acute Services Total 216,912 854 217,766 217,766 226,971 9,205

Community Health Services

Shropshire Community Trust 39,206 0 39,206 39,206 39,136 (70)

Other Community Services 3,959 150 4,109 4,109 3,801 (308)

Palliative Care 2,404 0 2,404 2,404 2,308 (96)

Community Health Services Total 45,569 150 45,719 45,719 45,245 (474)

Continuing Healthcare

Complex Care 25,643 0 25,643 25,643 34,260 8,617

Funded Nursing Care 8,199 0 8,199 8,199 6,404 (1,795)

Complex Care Team 967 0 967 967 1,173 206

Reablement 735 0 735 735 581 (154)

Continuing Healthcare Total 35,544 0 35,544 35,544 42,418 6,874

Mental Health Services

Midland Partnership FT 30,290 0 30,290 30,290 30,596 306

Other NHS Mental Health Contracts 169 0 169 169 (812) (981)

Mental Health NCA's 1,027 0 1,027 1,027 1,521 494

Mental Health - Other 1,492 0 1,492 1,492 1,692 200

Mental Health - TCP 0 300 300 300 217 (83)

Mental Health Services Total 32,978 300 33,278 33,278 33,214 (64)

Primary Care Services

Prescribing 47,204 0 47,204 47,204 48,111 907

Central Drugs 1,289 0 1,289 1,289 1,265 (24)

Oxygen 630 0 630 630 620 (10)

Enhanced Services 2,704 1,767 4,471 4,471 4,130 (341)

Out Of Hours 3,989 22 4,011 4,011 3,785 (226)

Primary Care Commissioning Schemes 1,433 0 1,433 1,433 1,580 147

Hospice Drugs 95 0 95 95 100 5

Prescribing Incentives 515 0 515 515 393 (122)

Care Home Advanced Scheme 206 0 206 206 260 54

Primary Care Team 1,737 140 1,877 1,877 1,508 (369)

Primary Care IT 782 163 945 945 861 (84)

Primary Care Services Total 60,584 2,092 62,676 62,676 62,613 (63)

Other

Patient Transport 3,165 0 3,165 3,165 3,118 (47)

NHS 111 741 0 741 741 747 6

Referral Assessment Service Team 462 0 462 462 362 (100)

Community & Care Co-ordinators 370 0 370 370 370 0

NHS Property Services 210 0 210 210 263 53

Better Care Fund 6,666 0 6,666 6,666 7,779 1,113

Shropshire Intervention Framework 0 500 500 500 0 (500)

Other 466 14 480 480 332 (148)

Other Total 12,080 514 12,594 12,594 12,971 377

Reserves

Commissioning Reserve 2,367 4,929 7,296 7,296 (1,276) (8,572)

Defined QIPP Gap 0 0 0 0 0 0

0.5% Non Recurrent Reserve 0 0 0 0 0 0

0.5% Contingency 2,217 0 2,217 2,217 0 (2,217)

Reserves Total 4,584 4,929 9,513 9,513 (1,276) (10,789)

Running Costs

Corporate Costs 3,972 43 4,015 4,015 3,131 (884)

Service Planning 735 0 735 735 1,082 347

Commissioning & Contracting 624 2 626 626 467 (159)

Strategy & Service Redesign 358 0 358 359 312 (47)

Finance 541 153 694 694 1,937 1,243

Governance 283 0 283 283 119 (164)

Nursing & Quality 178 6 184 184 156 (28)

Running Cost Total 6,691 204 6,895 6,896 7,204 308

Co-Commissioning 43,348 (315) 43,033 43,033 42,747 (286)

Co Commissioning Total 43,348 (315) 43,033 43,033 42,747 (286)

Total Expenditure 458,290 8,728 467,018 467,019 472,107 5,089

Budget (Surplus) / Deficit 13,300 58,337 71,637 71,637 76,726 5,089

Total Resource Limit 444,990 (49,609) 395,381 395,381 395,381 0

Total Expenditure 458,290 8,728 467,018 467,019 472,107 5,089

Total 13,300 58,337 71,637 71,638 76,726 5,089

Deficit Brought Forward (59,667) (59,667) (59,667)

In Year Deficit 11,970 11,970 17,059 5,089

2018/192018/19

Appendix 2 Statement of Financial Position – Year to 31st March 2019

2017/18 Nov18 Dec18 Jan19 Feb19 Mar19

£'000 £'000 £'000 £'000 £'000 £'000

Property, Plant &

Equipment Network Assets (IT)

Plant and Machinery

Networked Assets

Total PP&E

Cash & Bank Cash and Bank 197 76 375 (879) 43 88

Receivables Accounts Receivable (Outstanding Debtors) 2,424 1,804 2,324 1,428 1,242 2,145

Accrued Income 154 1,267 864 860 476 380

Accrued Debtors 50

Bad and Doubtful Debts (222) (164) (164) (164) (164) (458)

Other Receivables 54 (4) 1

Prepayments 1,492 1,179 2,269 610 418 10

Value Added Tax 171 126 30 99 110 165

Total Receivables 4,073 4,208 5,323 2,834 2,082 2,292

Accounts Payable Accounts Payable (Outstanding Creditors) (1,145) (1,331) (1,363) (458) (2,363) (1,134)

Other Creditors and Outstanding Payments (19) (1,637)

Accrued Liabilities (18,907) (20,849) (21,171) (19,468) (16,338) (16,419)

Provisions (104)

Accruals - Prescribing (8,444) (8,540) (8,389) (8,441) (8,485) (8,196)

Prescribing Incentive (445) (342) (332) (328) (348) (3)

Accruals - Home Oxygen Costs (47) (101) (103) (102) (99) (33)

Deferred Income (69) (52) (34) (17)

Payroll Payments - PAYE (72) (72) (73) (76) (79) (80)

Payroll Payments - National Insurance (81) (80) (84) (86) (89) (86)

Payroll Payments - Pensions (318) (441) (522) (445) (442) (508)

Payroll Payments - Other (4) (1)

Accruals - Partially Completed Spells (1,367) (1,367) (1,367) (1,367) (1,367) (1,824)

Total Payables (30,953) (33,192) (33,456) (30,806) (29,627) (29,920)

Total Assets (26,683) (28,908) (27,758) (28,851) (27,502) (27,540)

General Fund Funding Shortfall 2016/17 (18,063) (18,063) (18,063) (18,063) (18,063) (18,063)

Funding Shortfall 2017/18 (8,620) (8,620) (8,620) (8,620) (8,620)

In Year Funding 454,814 307,843 348,579 390,096 428,028 470,592

Funds available 436,751 281,160 321,896 363,413 401,345 443,909

Net (Expenditure)/Income current year (463,434) (310,068) (349,654) (392,264) (428,847) (471,449)

Total Equity (26,683) (28,908) (27,758) (28,851) (27,502) (27,540)

1

Agenda item: GB-2019-05.065

Shropshire CCG Governing Body: 8.05.19

Title of the report: QIPP Update – Month 12 (March 2019)

Responsible Director: Claire Skidmore, Chief Finance Officer

Author of the report: Kate Owen, Head of PMO

Presenter: Claire Skidmore, Chief Finance Officer


This report provides the Governing Body with a summary of the 2018/19 year end QIPP position and

reports the CCG’s programme of work for 2019/20.

Summary Headlines:

Month 12 figures report overall QIPP savings of £16.2m (3.7% of total allocation) against a

yearly target of £20.5m. This is a variance of -£4.28m or -21% against plan.

A significant amount of effort has been made across the organisation to achieve this level of

savings and despite schemes having fallen short of target by £4.3m, progress has been made

on a number of projects, some of which are continuing into 2019/20.

Learning will be taken to influence how the CCG deliver 2019/20 schemes, commencing with the

joint PMO and refinements to processes.

The current finance plan indicates an overall QIPP requirement for the CCG to meet its control

total in 2019/20 of £31m. £19.5m Schemes have been identified to date and therefore the plan

submitted to NHSE on 4th April misses the CCG’s control total requirement by £11.5m. Future

reports will reflect progress against current project plans and address actions to close the gap,

highlighting risks and mitigations where necessary

Recommendations:

To note the content of this report

2

Monitoring form

Agenda Item: GB-2019-05.065

Does this report and its recommendations have implications and impact with

regard to the following:

1 Additional staffing or financial resource implications

No If yes, please provide details of additional resources required

2 Health inequalities

No If yes, please provide details of the effect upon health inequalities

3 Human Rights, equality and diversity requirements

No If yes, please provide details of the effect upon these requirements

4 Clinical engagement

No If yes, please provide details of the clinical engagement

5 Patient and public engagement

No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability

Yes Slippage in delivery of QIPP directly impacts on the CCG’s

financial position.

Section 1 - Portfolio Report

3

Portfolio Report

Summary

2018/19

1. Month 12 Figures report overall QIPP savings of £16.2m (3.7% of total

allocation) against a yearly target of £20.5m. This is a variance of -£4.28m or -

21% against plan and provides an improved position compared to Month 11

forecast by £52k.

2. The improved forecast is in part due to improved Medicines Management

Scheme savings but also due to confirmed counting and coding and contract

challenges being agreed with providers and built into the financial position.

Please refer to 2018/19 QIPP Summary within Appendix 1 of this report.

3. It should be noted that significant effort has been made across the organisation

to achieve this level of savings and although overall, schemes have fallen short

of target by £4.3m, progress has been made on a number of projects, some of

which are continuing into 2019/20.

4. It was agreed at the QIPP Board meeting in April that a ‘lessons learnt’ report

should be presented by the Exec leads in May which would help with future

planning. A summary of this will be provided to the next committee.

2019/20

5. Please refer to 2019/20 QIPP plans within Appendix 2 of this report.

6. The current finance plan indicates an overall QIPP requirement for the CCG to

meet its control total in 2019/20 of £31m. £19.5m Schemes have been identified

to date and therefore the plan reported to NHSE on 4th April misses the CCG’s

control total requirement by £11.5m. Of the £19.5m identified schemes £7.6m has

been built into contracts.

7. The new combined PMO arrangements are now in place and meetings have

been held throughout the month, led by Executive leads and supported by

dedicated Finance, BI and Quality team members which have helped to gather

momentum on 2019/20 schemes.

8. Named Quality leads have been assigned to each project and have been

working with Scheme leads during April to finalise Quality Impact Assessments

for 19-20 projects, some QIAs are still outstanding at the time of this report.


4

9. All Business Cases have been received by the PMO with the exception of CHC

where final sign off is still outstanding however recent progress has been made

with a meeting chaired by Chief Finance Officer.

10. Final QIPP plans for 2019/20 have been shared with NHSE. All schemes have

been risk assessed and will continue to be reviewed throughout the year.

11. A Workshop has been arranged on 10th May to focus on further opportunities to

bridge the QIPP gap using intelligence gathered from various sources and

referencing Right Care packs produced in April 2019.

12. Relevant Schemes have been built into Provider contracts, with Emergency Care

schemes being removed from the Blended Tariff Block. Local Terms have been

agreed between the CCG and provider to mitigate risk of non delivery therefore it

will be essential that these terms are closely monitored.

13. QIPP and CIP (Cost improvement Plans) are now a standing agenda item for

Strategic Commissioning Boards within SaTH, RJAH, SCHT and MPFT.

14. A session is due to be held in Early May with Directors of Finance and Deputy

Directors across the system to review recent STP Transformational

Opportunities which have previously been identified.

There is also a plan for an STP QIPP group to be set up to include Finance,

Operational Managers and Clinicians.

15. As a feature of the new shared PMO arrangements within the CCGs, the team is

able to consider and share commissioner opportunities across the patch.


5

Finance Status

16. The CCG had a net QIPP target to deliver £20.5m savings in 2018-19 to assist in

the recovery of the organisation to bring it back into financial balance. In the

CCG’s original submitted plan, initiatives were identified to deliver £17.6m net

savings in the year.

17. The CCG achieved £16.2m on the planned savings of £20.5m (3.7% of total

allocation). The FOT increased slightly since the previous month and variance

from plan is reported as -£4.3m.

18. The performance of QIPP schemes in each area is summarised below and detail

given in Appendix 1.

Area M12 Plan M12 Act Var YTD Plan YTD Act Var Annual Plan FOT Var %

Commissioning 516 360 (156) 5,663 3,120 (2,544) 5,663 3,120 (2,544) -45%

Continuing Care Services 391 137 (255) 3,935 2,129 (1,806) 3,935 2,129 (1,806) -46%

Contracting 299 446 148 3,619 5,398 1,779 3,619 5,398 1,779 49%

Corporate 26 59 34 311 713 402 311 713 402 129%

Prescribing 353 324 (29) 4,032 4,398 366 4,032 4,398 366 9%

Finance 0 40 40 0 482 482 0 482 482 0%

Unallocated QIPP 494 0 (494) 2,969 0 (2,969) 2,969 0 (2,969) -100%

Grand Total 2,079 1,366 (713) 20,530 16,241 (4,289) 20,530 16,241 (4,289) -21%


6

Risk

19. The Following areas were identified as QIPP portfolio level risk in 2018/19:

Area Brief Description of Risk RAG Mitigating Actions

Finance Only partial realisation of

benefits associated with

schemes due to deliver in

Q4. This will affect the

final outturn and the

MTRP

Proposed stepping up of the QIPP Board

and governance arrangements -proposal

to Exec in September.

Action complete

Targeted deep dive at M6

Risk assessment of failing schemes

completed. Ongoing close monitoring /

diversion of resources

Update M10 –All at-risk schemes now

built into financial position

Portfolio Lack of overall capacity

and capability to deliver

the QIPP portfolio.

Volatility in the

composition of the

workforce leading to lack

of operational capacity.

Intervention and Support Agreement

Plan to maximise benefits from

deployment under the agreement

Commitment from Directors to prioritise

recruitment to posts

Update M11 – A large interim contingent

will leave in March 2019; some areas eg

Finance have almost completed their

recruitment and are considering joint

arrangements with Telford for QIPP

whilst others are still reliant on temporary

resource.

Planned and Urgent

Care

Capacity at SaTH

insufficient to engage in

elements of the CCG

QIPP programme.

This has been flagged as an issue at the

QIPP Board and was highlighted in

previous reports. It is now being actively

managed as an issue for Commissioning

and progress reported via QIPP

governance arrangements.

Risks to be carried forward into 2019/20 are as follows

Portfolio

Planned and Urgent Care

These will be reported in detail to future meetings.

7

Overall Summary and Conclusion

20. Month 12 Figures report overall QIPP savings of £16.2m (3.7% of total allocation)

against a yearly target of £20.5m. This is a variance of -£4.28m or -21% against plan

21. A significant amount of effort has been made across the organisation to achieve this

level of savings and despite schemes having fallen short of target by £4.3m, progress

has been made on a number of projects, some of which are continuing into 2019/20.

22. Learning will be taken to influence how the CCG manage to deliver 2019/20 schemes,

commencing with the joint PMO and refinements to processes.

23. The overall QIPP requirement for the CCG to meet its control total in 2019/20 is

£31m. £19.5m Schemes have been identified to date and therefore the plan reported

at 4th April misses the CCG’s control total requirement by £11.5m.

24. Future reports will reflect progress against current project plans and address actions to

close the gap, highlighting risks and mitigations where necessary.

Appendices

Appendix 1: 2018/19 Project Level Breakdown

Appendix 2: 2019/20 QIPP Plan

8

QIPP SUMMARY M12 - March 2019

Area of Spend (NHSE) Scheme

Ref

Scheme Description Plan

£'000

Actual

£'000

Variance

£'000

Plan

£'000

Actual

£'000

Variance

£'000

Annual

Plan

£'000

Forecast

Outturn

£'000

Variance

£'000

FOT MVNT

Commissioning Services 1819i42 Acute Kidney Injury Support the public and staff working in acute, primary and community care to better

understand kidney health and to help prevent, identify and manage AKI.

5 16 11 71 40 (31) 71 40 (31) 14

(blank) Faecal Calprotectin Testing 4 - (4) 32 (0) (32) 32 (0) (32) -

1819i26 Fracture Liasion Service 1 A Fracture Liaison Service (FLS) is a multidisciplinary service, which aims to

systematically identify, investigate, initiate treatment and integrate care for all

eligible patients who have suffered a fragility fracture.

7 - (7) 85 - (85) 85 - (85) -

1819i27 Frailty front door The aim of the FIT is to optimise every frail patient’s opportunity when presenting at

A&E/RSH Front Door for early identification, competent and timely assessment,

diagnostics and treatment to maximise their potential to:

• be discharged the same day preferably to their usual place of residence, or

• where admission is required to be discharged within 72 hours

75 (68) (143) 895 311 (584) 895 311 (584) (103)

ACU12 HISU To support HISU to access the most appropriate health and social care, reducing

demand on urgent and emergency care services - ambulance conveyance, A&E

attends and NEL admissions

13 31 18 150 368 218 150 368 218 -

1819i52 Inflammatory bowel disease (IBD) The telemedicine system used in the study focuses on helping the patient to

improve their self-management of the condition, through providing tailored

information about medication, treatment, and diet, medication reminders, recording

of symptoms over time, and allowing patients to send questions and seek advice

from clinicians involved in their care.

12 - (12) 73 - (73) 73 - (73) -

1819i18 MRI direct access (MSK and head) Reducing the number of repeat MRI scans currently created by the time gap between

a Direct Access scan and a consultant outpatient.

33 16 (17) 397 192 (205) 397 192 (205) -

1819i38 MSK Service Redesign The strategic objective of the programme is to implement a new evidence based

service model that improves patient outcomes whilst reducing expenditure levels to

expected norms.

317 (4) (321) 2,947 1,442 (1,505) 2,947 1,442 (1,505) (135)

1819i32 Non-Emergency Patient Transport (NEPTS) Review of inappropriately funded patient journeys 15 10 (5) 180 118 (62) 180 118 (62) -

(blank) Paeds zero length of stay Paeds zero length of stay 17 - (17) 200 - (200) 200 - (200) -

1819i16 Reduce Follow Up Outpatients [Cardiology/Respiratory first areas for review]Reduce Follow Up Outpatients [Cardiology/Respiratory first areas for review] 10 7 (3) 86 98 11 86 98 11 (9)

(blank) Reduce OP Follow ups at RJAH Reduce OP Follow ups at RJAH 10 10 - 123 123 - 123 123 - -

1819i30 Reduction Variation in GP Referrals /Demand management (MoO) [Cardiology/Respiratory first areas for review]Reduction Variation in GP Referrals /Demand management (MoO) [Cardiology/Respiratory first areas for review]8 (0) (8) 100 79 (21) 100 79 (21) (13)

(blank) RJAH QIPP RJAH QIPP 6 - (6) 75 - (75) 75 - (75) -

(blank) VBC Full year affect VBC Full year affect 21 (59) (80) 250 349 99 250 349 99 (96)

Alliance Agreement QIPP Alliance Agreement QIPP - - - - - - - - - -

PICU (Commissioning) PICU (Commissioning) - - - - - - - - - -

COPD Scheme COPD Scheme - - - - - - - - - -

Commissioning Services Total 552 (42) (594) 5,663 3,120 (2,544) 5,664 3,120 (2,544) (343)

Contracting Services 1819i66 Better Care Fund 117 50 (67) 1,400 300 (1,100) 1,400 300 (1,100) -

1819i47 Contract Challenges: A&E charging code / Elective code changeContract Challenges: A&E charging code / Elective code change 42 463 422 500 2,429 1,929 500 2,429 1,929 300

N/A DEXA tariff adjustment (RJAH) DEXA tariff adjustment (RJAH) 3 3 - 41 41 - 41 41 - -

COM01 Growth management Joint work on service change/ cessation with the provider to develop an operating

budget that does not require the £1,178k growth monies identified

98 98 - 1,178 1,178 - 1,178 1,178 - -

1819i21 Mental Health Rebasing Mental Health Rebasing 42 42 - 500 500 - 500 500 - -

Out of hours contract review Out of hours contract review - 73 73 - 750 750 - 750 750 -

Contract Rebasing - MSI Contract Rebasing - MSI - 17 17 - 200 200 - 200 200 -

Contracting Services Total 302 746 444 3,619 5,398 1,779 3,619 5,398 1,779 300

Primary Care Services 1819i13 Additional Pod Practices The POD will provide an additional method for patients to order their repeat

prescriptions, enabling increased patient empowerment and the ability for patients

to take control of their repeat medication requirements.

• Synchronise quantities of all repeat medication to the same length of treatment

• Amend quantities to ensure that patients do not have excess of their medication

• Remove items to “past” if they have not been ordered for 6 months or more

• Refuse prescriptions that are requested more than 7 days ahead of the due date.

• Discontinue any medicines that the patient reports they are no longer using and

informing the Practice clinician

73 36 (37) 141 104 (37) 141 104 (37) (37)

1819i44 Appliances 12 - (12) 97 62 (35) 97 62 (35) -

PRI03 Care home and domicillary services • To promote the safe and effective use of medicines in care homes by advising on

processes for prescribing, handling and administering medicines.

• Recommend how care and services relating to medicines should be provided to

people living in care homes.

9 4 (5) 107 303 196 107 303 196 4

1819i49 Drug Switches / Switching Programme 22 1 (21) 265 952 687 265 952 687 1

1819i51 NHS DOLCV Limit products of low clinical effectiveness, where there is a lack of robust evidence

of clinical effectiveness or there are significant safety concerns

26 41 15 400 233 (167) 400 233 (167) 1

PRI01 Prescription Ordering Direct (POD) The POD will provide an additional method for patients to order their repeat

prescriptions, enabling increased patient empowerment and the ability for patients

to take control of their repeat medication requirements.

• Synchronise quantities of all repeat medication to the same length of treatment

• Amend quantities to ensure that patients do not have excess of their medication

• Remove items to “past” if they have not been ordered for 6 months or more

• Refuse prescriptions that are requested more than 7 days ahead of the due date.

• Discontinue any medicines that the patient reports they are no longer using and

informing the Practice clinician

118 64 (54) 1,502 1,179 (322) 1,502 1,179 (322) 42

PRI02 Scriptswitch A continuation of using the existing ScriptSwitch technology to identify potential

drug switches to GPs for potential drugs switches. ScriptSwitch is a prescribing

decision support tool which integrates into practices clinical systems. This is the tool

chosen by the CCG to implement key formulary decisions.

40 112 72 501 660 160 500 660 160 112

1819i43 Secondary Care Optimisations - Biosimilars Efficiency savings jointly delivered in following areas:

- Biosimilars incl anti TNF drug alternatives

29 8 (21) 353 418 65 353 418 65 -

1819i44 Secondary Care Optimisations - Other Blueteq 39 77 38 467 252 (215) 467 252 (215) 61

1819i51 Self-Care Aim is to continue to educate patients on self-care and encourage practices and

pharmacy to promote self-care and Pharmacy first. The costs to the NHS for many of

the items used to treat minor conditions are often higher than the prices for which

they can be purchased over the counter as there are hidden costs.

13 (2) (16) 200 107 (93) 200 107 (93) (25)

Scriptswitch budget review - 11 11 - 128 128 - 128 128 -

Primary Care Review - - - - - - - - - -

Primary Care Services Total 382 352 (30) 4,032 4,398 366 4,032 4,398 366 160

Continuing Health Care Services (blank) AQP Warrington Tool This project is to introduce a Resource Allocation System (RAS) often referred to as

the Warrington Tool for the pricing of complex care packages, in order to reduce

annual costs in 2018/19 and beyond

41 - (41) 278 - (278) 278 - (278) -

1819i21 CAS (Out of area mental health) Where possible the patients will be transferred closer to Shropshire if they are

currently located further away

8 1 (7) 84 40 (44) 84 40 (44) 1

1819i53 CHC Provider Framework (Incl Morris Care Block) To establish a provider framework for nursing homes 33 - (33) 224 - (224) 224 - (224) -

1819i56 ELIGIBILTY This project is about the eligibility criteria. 22 - (22) 295 32 (263) 295 32 (263) -

1819i54 Funded Nursing Care This project is to tighten the application of the eligibility criteria for access to NHS-

Funded Nursing Care (FNC) payments.

11 - (11) 676 48 (627) 676 48 (627) -

1819i64 Hospice extension (hospice at home) To work collaboratively between commissioner and provider in relation to high

volume, hospice at home provision and scope potential for increased use of the

service at a lower cost.

21 - (21) 250 - (250) 250 - (250) -

CHC01 Joint Assessment Tool Application of the Telford Tool to achieve a revised and lower health contribution

percentage similar to that employed bu other CCGs including the neighbouring

Telford & Wrekin CCG. Use of the revised assessment tool to commence 1st April

2017 and apply to all review cases.

28 75 47 333 898 565 333 898 565 0

1819i58 Joint children’s placements Joint children’s placements 21 - (21) 250 - (250) 250 - (250) -

1819i57 Review of PICU at SSSFT Review of PICU at SSSFT. Work collaboratively between commissioner and provider

in relation to high volume, high cost areas of mental health and CHC provision in

Shropshire

21 - (21) 250 (0) (250) 250 (0) (250) -

1819i61 S117 Review S117 Review 41 14 (26) 491 250 (241) 491 250 (241) -

1819i55 Transforming Care Partnership Working with NHS England the CCG has identified a cohort of up to five patients who

can potentially be discharged from the CCG’s learning disability services into the

community or other appropriate settings.

66 - (66) 452 - (452) 452 - (452) -

1819i3 Twilight Nursing Service Twilight Nursing Service 70 - (70) 353 - (353) 353 - (353) -

CHC AQP Introduction of a pricing framework across all contracts by start of Q4. Specification to

CCC in August

- - - - - - - - - -

High Cost Patients - 5 5 - 400 400 - 400 400 -

Fast track Reviews Specific programme of work being undertaken to get Fast track (FT) patients

reviewed quicker. It is common for FT patients to drop to lower level of care (FNC)

following review. Savings against FYF to date £128k. Risk assessed forecast (75%)

level at £192k

- - - - 151 151 - 151 151 -

Wolverhampton Council CHC contract Review of CHC contracts - 23 23 - 276 276 - 276 276 -

Continence Continence - 14 14 - 34 34 - 34 34 (66)

Continuing Health Care Services Total 381 132 (250) 3,935 2,129 (1,806) 3,935 2,129 (1,806) (66)

Finance Q1 Budget review - 40 40 - 482 482 - 482 482 -

- 40 40 - 482 482 - 482 482 -

Corporate (blank) Running Costs 26 34 8 311 405 94 311 405 94 -

Estates & Facilities - 26 26 - 308 308 - 308 308 -

Establishment - - - - - - - - - -

Corporate Services Total 26 59 34 311 713 402 311 713 402 -

Unallocated QIPP Unallocated QIPP 486 - (486) 2,969 - (2,969) 2,969 - (2,969) -

486 - (486) 2,969 - (2,969) 2,969 - (2,969) -

Grand Total 2,129 1,287 (842) 20,530 16,241 (4,289) 20,530 16,241 (4,289) 52

* The schemes that have been shaded in grey are those that have been deferred ot stopped in year. Prev. Month forecast 16,190 52

In Month 2018/19 Year to Date Forecast

9

Appendix 2 – 2019/20 QIPP Plan

QIPP Scheme 2019/20 Gross Investment 2019/20 Net Savings High Confidence_ Some Confidence Low Confidence

Autism AND Asperger's Provision 20 0 20 0 0 20

COPD Scheme 656 0 656 0 656 0

Dermatology Commissioning Options 42 0 42 42 0 0

Fracture Liasion Service 115 220 -105 -105 0 0

Frailty front door 420 420 0 0 0 0

Heart Failure 374 0 374 0 374 0

HISU 120 0 120 0 120 0

Home Oxygen Assessment & Review Service 51 0 51 0 51 0

Shropshire Care Closer to Home Transformation Programme - Demonstrator Sites 1,000 0 1,000 0 0 1,000

Shropshire Care Closer to Home Transformation Programme - Admission Avoidance Team 2,900 1,000 1,900 0 0 1,900

Additional VBC 250 0 250 0 250 0

MSK 3,092 0 3,092 3,092 0 0

Category 1 PLCV 35 0 35 35 0 0

Ex-Tel (SaTH) 764 0 764 0 764 0

Ex-Tel (Investment) 0 133 -133 0 -133 0

CAS (Out of area mental health) 290 87 203 0 0 203

CHC AQP 329 0 329 0 0 329

Collaborative Commissioning 300 0 300 0 0 300

Joint children’s placements 500 0 500 0 0 500

Review Programme 452 0 452 0 0 452

Additional CHC 1,000 0 1,000 0 0 1,000

RJAH 852 0 852 852 0 0

SaTH 623 0 623 623 0 0

Shropshire Community Health Trust Contract 1 350 0 350 0 80 270


Shropshire Community Health Trust Contract (OOH Service) 757 0 757 757 0 0

Running Costs Review 350 0 350 175 0 175

Running Costs 20% 413 0 413 0 0 413

Appliances (Stoma) 40 22 18 18 0 0

Appliances (Wound) 180 0 180 180 0 0

Care home and domicillary services & polypharmacy 440 24 416 416 0 0

Diabetes 150 47 103 103 0 0

Drug Switches / Switching Programme 800 0 800 800 0 0

Prescription Ordering Direct (POD) 1,030 578 452 452 0 0

Respiratory 220 20 200 200 0 0

Secondary Care Optimisations - Biosimilars (RJAH) 431 0 431 431 0 0

Secondary Care Optimisations - Biosimilars (SaTH) 386 0 386 386 0 0

Self-Care 200 0 200 200 0 0

Prescribing Stretch Target 133 0 133 0 0 133

Co-Commissioning Efficiencies 216 0 216 0 0 216

Mental Health Rebasing 1 600 0 600 600 0 0


22,088 2,550 19,538 9,565 3,062 6,911

1



Provider Quality Exception Report


Ms Dawn Clarke, Director of Nursing, Quality and Patient Experience


Miss Samantha Bunyan - Head of Quality and Safety with input from Nursing and Quality Team

Presenter:

Ms Dawn Clarke, Director of Nursing, Quality and Patient Experience

Purpose of the report: The CCG commissions services from a number of providers and the quality and safety of these services is assured through the monitoring of quality schedules and site visits.

Each provider contract has a clinical quality review meeting (CQRM) that meets on a regular basis and reviews a range of quality indicators that are included within the quality schedules. These indicators include patient safety issues, complaints, serious and untoward incidents, infection prevention and control and other indicators of quality improvement and service quality. The purpose of the report is to provide assurance to the Governing Body that the processes are in place to monitor quality indicators and escalate and ensure remedial action is in place where poor performance is identified.

Key issues or points to note: Shrewsbury and Telford NHS Hospitals

Concerns remain around staffing levels and high agency use in Shrewsbury and Telford Hospitals Emergency Departments and some ward areas. Health Education England and NHS Improvement continue to work with the Trust to support recruitment.

A further unannounced Care Quality Commission inspection was conducted in the Emergency Departments and in Maternity Services on the 15th of April. The report is awaited.

To ensure that Sepsis requirements were adhered to within the Emergency Departments whilst the high percentage of Agency use continued, in August 2018, twice daily observation and sepsis audits were requested by the CCGs to monitor policy compliance with policy implementation by staff including agency staff. The CCGs recently raised concerns with SaTH that the Safe Today reports were highlighting that these audits were not being undertaken due to capacity in the team. At the Safety and Oversight Group the SaTH Chief Executive committed to ensuring these audits would be maintained.

The SaTH Clinical Quality and Risk meeting (CQRM) will take a greater role in system wide assurance of the Trust's Improvement Plan. The monthly Safety and Oversight Group chaired by NHS Improvement will continue for a further six months.

2

Shrewsbury and Telford Hospitals have shown some improvement in identifying Sepsis but acknowledge the need for on-going work throughout the rest of the Trust.

12 hour trolley breach reporting has improved. Harm pro-formas received to date have confirmed that no significant harm has occurred as a result of these delays but this will continue to be monitored.

Shropshire Community Health Trust

Work progressing the Health Passports for Looked After Children in Shropshire is monitored by the CCG Designated Nurse for Looked After Children and at CQRM.

Robert Jones and Agnes Hunt NHS Foundation Trust

RJAH Care Quality Commission Report identified Critical Care as ‘Requiring Improvement’. An action plan had been completed and will be monitored at the Clinical Quality and Risk Meetings (CQRM)

RJAH report an increase in patients not attending Out-Patient appointments. There is work underway to review causality and address any issues.

Midlands Partnership Foundation Trust

CQC are currently undertaking a planned inspection of the Trust.

Actions required by Quality Committee Members: To receive and note the content of the Provider Quality Exception report.

3

Monitoring Form

Agenda Item: GB-2019-05.067 Shropshire CCG Governing Body: 8.05.19





4 Clinical engagement Yes If yes, please provide details of the clinical engagement

Clinical input routinely sought as required.

5 Patient and public engagement Yes If yes, please provide details of the patient and public engagement

Healthwatch are members of the Quality Committee. Patient feedback is used in the process to triangulate information

6 Risk to financial and clinical sustainability No If yes how will this be mitigated

4

NHS Shropshire CCG SCCG Governing Body: 8-05-2019

Agenda Item: Quality and Patient Safety Exception Report Executive Summary and Actions Required 1 The CCG commissions services from a number of providers and the quality and safety of

these services is assured through the monitoring of quality schedules and site visits.

2 This report provides a high level summary of those quality indicators and is submitted to the CCG Governing Body for assurance purposes.

3 The purpose of this report is to provide the Governing Body with accurate, relevant information and assurance regarding the quality and safety of commissioned services. The information presented in this report is taken from a variety of sources including provider Clinical Quality Review meetings (CQRM), performance reports, and other relevant information including the nationally contracted processes entered into by commissioners and service providers. These arrangements are outlined in detail in the NHS standard contracts 2019/20.

Summary of Main NHS provider contracts Shrewsbury and Telford Hospitals NHS Trust (SaTH) 4 Concerns around staffing levels remain, with reports of nursing staff shortages necessitating

the closure of the Clinical Decisions Unit at Princess Royal Hospital over the weekend of the 13th and 14th April. However the SaTH Medical Director reported that safe patient care was provided throughout this period. Reports are received daily from SaTH and averages of 50% substantive versus locum nurse staffing levels are noted. Workforce is reported monthly at CQRM and continues to be monitored. Health Education England and NHS Improvement continue to work closely with the Trust to support recruitment plans.

5 An unannounced Care Quality Commission inspection was conducted in the Emergency Department and in Maternity on the 15th of April. The report is awaited.

6 The SaTH CQRM will take a greater role in system wide assurance of the Trust's Improvement Plan. The monthly Safety and Oversight Group chaired by NHS Improvement continues for a further six months. Forthcoming agendas for CQRM will be divided into two sections: - Contractual assurance completing oversight of contractual requirements on an exceptions

basis - Quality Improvement Plan assurance

7 Sepsis: NICE guideline on Sepsis was published in 2016 and provides an evidence-based approach to recognising and initiating treatment for suspected Sepsis. Early warning scores are used to improve the detection of clinical deterioration of acutely ill people in hospital. In December 2017, NEWS2 (National Early Warning Score Version 2) received formal endorsement from NHS England to become the early warning score for identifying acutely ill patients, including those with Sepsis, in hospitals in England. The NHS England initiative to roll out NEWS2 across the NHS with a focus on achieving 100% coverage of acute and ambulance settings was set to be achieved by March 2019. Part of this initiative was to embed Sepsis compliance into CQUINs for 2018/19.

5

8 NICE guideline on Sepsis was published in 2016 and provides an evidence-based approach

to recognising and initiating treatment for suspected Sepsis. SaTH have shown some improvement in identifying Sepsis but acknowledge the need for on-going work throughout the rest of the Trust, primarily to include Acute Inpatients where reports show that only 61.1% of Sepsis cases are identified within one hour, 57.1% of Sepsis cases are provided with IV antibiotics within one hour, and only 37.5% of Sepsis cases are provided with IV antibiotics within 72 hours. It was clarified that although improvement is required in the identification and treatment of Sepsis, figures are skewed due to issues in accurate reporting, as previously mentioned at SaTH CQRM forum. The Director of Nursing at SaTH further agreed that compliance with the Sepsis Bundle is a key priority from a quality perspective for SaTH.

9 SaTH have developed an action plan to address and track progress. Although the action plan is partially complete, data reported at CQRM has not shown sustained or significant improvement in Commissioning for Quality and Innovation (CQUIN) targets in the previous three quarters. The report for the final quarter of 2018/19 is awaited.

10 The Sepsis CQUIN has not been carried into 2019/20. However, to continue to monitor progress, Local Quality Reporting Requirements on several Sepsis indicators have been included in the 2019/20 contract and have been agreed by SaTH.

11 In August 2018, to ensure that Sepsis requirements were adhered to within the Emergency

Departments whilst the high percentage of Agency use continued, twice daily observation and Sepsis audits were requested by the CCGs to monitor policy compliance with policy implementation by staff including Agency staff. The CCGs recently raised concerns with SaTH that the Safe Today reports were highlighting that these audits were not being undertaken due to capacity in the team. At the Safety and Oversight Group the Chief Executive committed to ensuring these audits would be maintained.

12 Discharge Letters and X-Ray Reports: In January’s Quality Exception Report, it was documented that a thematic analysis of several Serious Incidents (SI) and NHS 2 NHS (N2N) concerns had revealed issues regarding the quality of content and delays in discharge notifications and X-Ray (XR) reporting notifications from Shrewsbury and Telford Hospitals (SaTH). This is an area identified for rapid improvement but the CCG has been advised that it will take time to implement permanent changes due to the complexity of communication between several information management systems, departments and clinicians across departments and where ultimate accountability lies. Progress had not been verified and was escalated at CQRM on 26 March 2019 and at Quality Committee in April 2019. Concerns were also escalated during the Planned Care Working Group meeting on 28 March 2019 and this will be discussed at the forthcoming CQRM.

13 X-Ray Reporting Concerns: In order to benchmark and monitor improvement, local quality reporting requirements on X-Ray reporting have been included and agreed by SaTH for 2019/20.

14 Staff Survey: Results of SaTH staff survey were received at CQRM in March 26th 2019. Response rates were in keeping with the national average. Three areas were noted for improvement with safety culture reported as poor performance nationally. Plans have been made to engage staff in several projects and workshops.

15 12 Hour Trolley Breaches: Following concerns raised at CQRM and by NHS England

(NHSE) on delays in receiving 12 hour trolley breach notifications, the process of reporting was mapped by the Trust and by the CCGs.

6

The breaches had been advised to NHSE in good time. However, NHSE’s standard operating procedure required localising to Shropshire and Telford & Wrekin on-call information pack. This has been amended and approved by NHSE. There have been no further delays reported.

16 The Maternity Performance and Quality Reporting Dashboard has been discussed and

agreed with the CCGs and is monitored monthly at the Clinical Quality and Risk Meeting

(CQRM).

17 An unannounced Care Quality Commission (CQC) inspection was conducted in Maternity

on 15th of April. Progress following the 2018 report was noted with some recommendations

made.

Shropshire Community Health NHS Trust (SCHT) 18 Safer Staffing: The Trust report reflects stabilisation of staffing levels. Vacancies remain

highest in allied healthcare roles and with physiotherapy in particular at Ludlow and Bishop’s Castle.

19 Medicines: There is assurance that the Trust is learning from medication errors and it has

submitted a business case to implement electronic prescribing to inpatient areas. 20 Looked After Children: Further to the offer of funding for a catch-up program for the

provision of Health Passports, it was confirmed that progress is being made. Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation 21 Care Quality Commission (CQC) Report: The CQC report from the inspection conducted

in November 2018 was published on 21st February 2019. The overall result was ‘Good’ with an ‘Outstanding’ achievement for caring. An action plan had been completed with all but one action outstanding. There are no issues anticipated with completion.

22 Did Not Attend Appointments (DNA): The Trust reported a rise in DNA generally across all

out-patient areas. The DNA rate in February was 5.46%, which amounted to 478 missed appointments. Actions to mitigate this included telephone calls; text messages; appointments made no longer than 6 weeks to be seen. Plans are now in place to provide satellite out-patient clinics in Stoke. It was suggested to carry out a retrospective audit into reasons why patients did not attend appointments so that issues may be addressed.

West Midlands Ambulance Service (WMAS) and NHS 111 23 Safeguarding: Presentations were received from WMAS and NHS 111 on safeguarding

concerns and training of staff. There was a good attendance of safeguarding designated professionals from West Midlands and discussion was around common concerns, agreement of principles and report design for CCG’s. It was highlighted that NHS 111 produce a report for Shropshire and Telford and it was agreed that this design would be shared with WMAS. There was agreement to set up a task and finish group to look at a template for reporting for the West Midlands for all safeguarding matters for children and adults.

7

Serious Incident Reporting 24 NHS Improvement has statutory duties to collect patient safety information from all

providers of NHS-funded care, and to provide advice and guidance on reducing risks to patient safety, supporting the delivery of better outcomes for patients. Development is underway to provide a single port of call for recording, accessing, sharing and learning from patient safety incidents, in order to support improvement in the safety of NHS-funded services at all levels of the health system.

25 Update on the Patient Safety Incident Management System

• The Serious Incident Framework will be renamed and is due to be published in June/July 2019

• Primary Care will be included in the new framework • More partnership working is proposed in the sense of having an investigation team

consisting of representatives from across the health economy • Investigations will be more joined up. For example, one patient may have an

investigation ongoing for three separate incidents and the proposal is that there should be one investigation encompassing all concerns

• The investigation will focus more on learning outcomes • The investigation will look at the whole patient pathway, for example home to hospital

26 Healthwatch Stakeholder Group

Shropshire CCG attended the Stakeholder Group along with representatives from Sustainability and Transformation Partnership, Midlands Partnership Trust, Shropshire Community Health Trust and the Local Authority. Shropshire CCG gave an overview of how quality care of providers is assured. Future priorities of the organisations present were discussed.

Recommendations To note the key points / concerns / risk raised. To receive this report for information and assurance regarding the steps being taken to improve and monitor the quality, safety and patient experience in commissioned services.

1



Governing Body SCCG Performance Report 2018/19


Julie Davies, Director of Performance & Delivery


Charles Millar, Head of Planning, Performance and Contracting

Presenter:


Purpose of the report: To update the governing body on the CCGs performance for the last quarter of 2018/19 against the key performance indicators that the CCG is held accountable for with NHS England. This overview provides assurance on performance achievement against targets/standards at CCG and provider level as appropriate, and the delivery and contractual actions in place to address areas of poor performance.

Key issues or points to note: The attached report sets out Shropshire CCG’s performance against all its key performance indicators for Month 10 and 11 where available for 2018/19. They key standards that were not met YTD for SCCG are :- 62 day RTT 2wk wait (Breast) 2wk wait from GP referral A&E 4hr target Ambulance handovers >30mins and >1hr RTT

The 62day RTT, 2wk Breast symptoms and overall 2wk wait performance targets for the CCG were not achieved. The improvement plans continue to be closely monitored however recent improvements in the 2 wk breast symptoms target has not continued due to the loss of a Breast Radiologist and being unsuccessful in recruiting a replacement. SaTH now don’t believe they can recover this and the wider 2wk target until October 2019. The overall trajectory for the recovery of 85% 62day RTT target has also now been affected by this and has also slipped to October 19. This does not include Urology despite some improvements in elements of the surgical pathways as a result of the joint working with UHNM, the underlying consultant workforce capacity issues remain. This and the breast radiologist workforce issues have been escalated to the regional cancer alliance group. Bi -weekly calls remain in place with NHSE to also monitor delivery against these plans and provide support as required. The CCGs overall

2

cancer performance is also affected by out of county providers and this is continually progressed through the corresponding lead commissioners via our contract team with support as required from NHSI & NHSE. The IAPT access target run rate of 19% was achieved in March as per the commitment from MPFT. A&E performance remains significantly challenged with February’s performance worse than January’s and the same period last year. However there was an improvement in March achieving 72.8% which was better than March 2018 and was also the Trust’s best performance since August 2018. Demand for Shropshire remains slightly above plan in months 11& 12 but is along regional trends. Workforce levels and systems and processes remain the key underlying issue. Performance remains strong in reducing the number of stranded patients (LoS >7days). The national ECIP team remains full time in SATH to focus on improving their internal systems and processes to support our system’s recovery. The system with the support of ECIST has just completed a review of the key priority action areas for 18/19 and a revised set of priority action areas is being finalised with the A&E Delivery Board and will be included in the next Governing Body Performance report. Both > 1hr and >30mins have improved in February and further in March, but delays continue to be mainly due to peak volumes of activity. Work continues between SATH and WMAS to further improve ambulance handovers but this is severely tested when ambulance conveyances exceed 5-6 an hour on each site which is now occurring more regularly. The short term task and finish group has been set up specifically to understand the increase in ambulance demand seen is reporting its initial findings this month to the Governing Body and is now on phase two of the work to try and reduce the demand and as a result develop an improvement plan to reduce the number of >1hr ambulance handover delays. The CCG has continued to fail the RTT target in January and February as a result of winter pressures and escalation into both sites Day Surgery Units. December. The recovery of this target was planned based on a full elective programme being restarted from the 1st April. However the original plan is being reviewed as this has not been achieved due to continued bed pressures. RJAH remain below target but have reported unofficially that they have achieved the 92% target for March 2019. The CCG had 0 over 52 wk waiters at the end of February which was ahead of the trajectory agreed with NHSE. This continues to be monitored weekly by the CCG for its patients across all providers to continue to minimize any >52 wk breaches.

Actions required by Governing Body Members: The Governing Body is asked to NOTE the contents of the report and the CCG actions contained within to recover performance in those areas which are currently below target.

3

Monitoring form



1 Additional staffing or financial resource implications Yes/ No If yes, please provide details of additional resources required

2 Health inequalities Yes/ No The action taken by the CCG to deliver all its constitutional targets will address

any health inequalities currently present in the areas the performance targets are not being met.

3 Human Rights, equality and diversity requirements Yes/ No If yes, please provide details of the effect upon these requirements

4 Clinical engagement Yes/ No If yes, please provide details of the clinical engagement

5 Patient and public engagement Yes/ No If yes, please provide details of the patient and public engagement

6 Risk to financial and clinical sustainability Yes/ No The CCG would fail to get its full Quality Premium Payment if it fails any of its key

performance premium indicators.

Page | 1

Governing Body

Shropshire Clinical Commissioning Group (CCG)

Performance Report May 2019/20

INTRODUCTION

1. This performance report provides an overview of the key performance indicators (KPIs)

that the CCG is held accountable for with NHS England during 2018/19. They are part of

the CCG’s Improvement and Assessment Framework (IAF) for 2018/19 detailed under

the Better Care section and linking in with the six national clinical priorities. These are

mental health; dementia, learning disabilities, cancer, diabetes and maternity.

2. The monthly data reported is for February 2019 and March 2019 where data is available.

3. Some of the CCG Improvement and Assessment Framework indicators have been

updated where new data has been made available.

4. The overview provides assurance on performance achievement against

targets/standards at CCG and provider level as appropriate, and the delivery and

contractual actions in place to mitigate.

DASHBOARD

5. The dashboards below provide details of indicators and their RAG rating against national

and local standards within service areas. Following these, there are details of the high

risk indicators and the mitigation in place.

6. Where key standards were not achieved in 2017/18, trajectories have been set as part of

the Sustainability & Transformational Fund (STF), in the 2018/19 planning round. For

Robert Jones and Agnes Hunt Hospital and Shrewsbury and Telford Hospital Trust,

these included;

A&E 4 Hour Wait

18 Weeks RTT Incompletes

Cancer 62 days wait

Page | 2

Shropshire CCG – KEY PERFORMANCE INDICATORS

Indicator Description

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Cancer Diagnosed at Early Stage - % of cancers diagnosed at

Stage 1 & 2

Cancer 62 Day Waits - % of patients receiving first definitive

treatment for cancer within 62 days of an urgent GP referral

for suspected cancer

2017/18 83.5% 85% 84.8% 82.9% 83.5% 81.3% 79.2% 81.1% 73.0% 82.7% 84.7% 63.9% 66.7% 78.5%


treatment for cancer within 62 days of referral from an NHS

Cancer Screening Service

2017/18 88.6% 90% 86.7% 100.0% 92.3% 93.3% 93.3% 100.0% 91.7% 71.4% 93.3% 95.2% 81.8% 90.8%


treatment for cancer within 62 days of a consultant decision

to upgrade their priority status

2017/18 88.2%No

National

Standard

83.0% 82.2% 91.2% 93.5% 94.6% 87.5% 81.1% 92.9% 80.8% 97.2% 76.3% 87.6%

Cancer 2 Week Wait - % of patients seen within two weeks of

an urgent referral for suspected cancer2017/18 93.0% 93% 93.6% 93.1% 82.4% 81.3% 78.6% 86.7% 82.2% 84.5% 88.7% 89.6% 90.1% 86.3%

Cancer 2 Week Wait - % of patients seen within two weeks of

an urgent referral for breast symptoms2017/18 91.5% 93% 92.2% 89.3% 37.1% 31.0% 54.9% 79.8% 35.6% 55.6% 87.7% 87.5% 58.5% 68.1%

Cancer 31 Day Wait - % of patients receiving first definitive

treatment within 31 days of a cancer diagnosis2017/18 99.0% 96% 97.8% 98.9% 99.1% 99.4% 98.4% 99.4% 99.5% 98.4% 96.5% 94.9% 96.9% 98.1%

Cancer 31 Day Wait - % of patients receiving subsequent

treatment for cancer within 31 days where that treatment is

surgery

2017/18 97.3% 94% 100.0% 100.0% 100.0% 97.2% 93.5% 95.3% 100.0% 95.1% 97.5% 85.0% 88.6% 95.7%



anti cancer drug regimen

2017/18 99.9% 98% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.3% 100.0% 100.0% 100.0% 100.0% 99.9%



radiotherapy treatment course

2017/18 99.3% 94% 100.0% 98.1% 100.0% 98.5% 95.2% 93.8% 97.3% 92.6% 97.7% 96.4% 100.0% 97.2%

One-year survival for all cancer

Cancer patient experience of responses, which were positive

to the question "Overall, how would you rate your care?"2015

8.7

(England)

2016

50.6%

(England 52.6%)

2015

72.4%

National 72.3%

2017

8.9 (CCG)

Can

cer

Page | 3

CANCER

7. As at February 2019, 4 cancer indicators did not achieve the standard in the month:

62 day wait – Urgent, 66.7% against 85% standard

62 day wait – screening, 81.8% against 90% standard

2 week wait – Breast, 58.5% against 93% standard

2 week wait – Urgent, 90.1% against 93% standard

8 Performance on 14 day Breast symptomatic rates has fallen back in February following

some improving figures in the last few months. Workforce issues within Radiology have

worsened and the resulting impact on 2 week wait performance will continue through the

early months of the 2019/20 year. Steps to improve booking processes administration

are being commenced following a ‘deep dive’ into current arrangements. The quality

impact of this issue has now been escalated to the Clinical Quality Review Meeting,

following the April Planned Care Working Group and the broader staffing issues have

been raised at the regional Cancer Alliance.

9 Demand for Urological cancer treatments continues to be an issue and capacity remains

a problem both locally and regionally. The prostatectomy pathway is being reviewed to

enable earlier access to diagnostic MRI. Some improvements in surgical pathways as a

result of patients now being treated at UHNM have been seen.

10 Improvement plans are in place for all tumour sites with the exception of Urology. A plan

of actions taken (and resulting impact) in Urology and those planned by the Trust will be

agreed by mid May to provide assurance that everything the Trust can do is being done

to improve this speciality but beyond that the issues have been escalated to the

regulator and regional alliance for additional support. The other plans continue to be

monitored jointly by the Trust, CCGs and NHSE and NHSI on a fortnightly basis.

Discussions with tertiary providers are being held to improve the flow of referral

pathways and diagnostic reporting. Patients are being encouraged to take the earliest

offered date through changes in the booking centre scripts to emphasise benefits of

earlier investigation. The performance at SaTH by tumour site for February 2019 is

detailed below compared with the national average where possible.

2 week performance 62 day performance

Tumour Site SaTH National Comparison SaTH National Comparison

Breast 93.0% 88.6% Better 85.7% 88.9% Worse Childrens cancer 100% 92.6% Better

Gynaecological 91.3% 95.3% Worse

Haematological 96.0% 96.0% Similar

Head & Neck 90.8% 96.4% Worse

LGI 89.6% 92.6% Similar 50% 66.3% Worse Lung 89.8% 95.8% Worse 66.7 68.1% Similar Skin 87.1% 96.2% Worse 88.5% 94.6% Worse

Testicular 100% 97.7% Better UGI 84.7% 92.4% Worse 64.3% N/A Urological 90.0% 94.7% Worse 45.2% 67.8% Worse

11 The 62day performance deteriorated in February. Additional theatre sessions and clinics

are being scheduled where possible. Weekly assurance and performance meetings

Page | 4

continue to be held. Continuing difficulties in resourcing workforce in SaTH will now

impact on the ability to meet the original planned 85% compliance in the 62 day wait

standard from July. This is now expected from October. SaTH are progressing a range

of options to mitigate the workforce constraints which have also been escalated to the

regional Cancer Alliance.

12 The cancer dashboard also details 3 further indicators, which are all reported on an

annual basis. These have been updated for the most recent published data. The

indicators are; diagnosis at early stage 1&2 which has fallen to 50.6% , one year

survival which has increased to 72.4% and cancer patient experience which remains at

8.9. Baselines and the latest position are shown. The patient experience RAG rating is

based on a survey where patients are rating their care (excellent or very good). The

CCG will investigate the factors behind the reduction in the rate of early cancer

detection, although it should be noted the quoted figure relates to the 2017 calendar

year.

13 There were 8 x 104 day cancer breaches for Shropshire CCG and 12 in total reported

by SaTH, for February 2019. All long wait cancer patients are reviewed through CQRM

to ensure processes are not likely to cause harm and that any systemic reasons for

delay should be investigated, understood and remedied.

Page | 5


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Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD

IAPT Roll Out - Proportion of people that enter treatment

against the level of need in the general population

(CCG/SSSFT)

2017/18 16.1% 19% 1.1% 1.3% 1.3% 1.2% 1.4% 1.1% 1.5% 1.4% 1.2% 1.4% 1.5% 1.9% 16.4%

IAPT Recovery Rate (CCG/MPFT) 2017/18 54.6% 50% 56.5% 50.3% 55.9% 52.7% 51.3% 57.6% 52.6% 50.2% 59.6% 53.7% 51.8% 56.1% 53.8%

75% of people with relevant conditions to access talking

therapies in 6 weeks (CCG/MPFT)2017/18 92.1% 75% 95.2% 90.8% 93.2% 95.2% 94.6% 94.6% 96.1% 95.1% 97.9% 94.8% 99.4% 99.4% 95.4%

95% of people with relevant conditions to access talking

therapies in 18 weeks (CCG/MPFT)2017/18 98.2% 95% 100.0% 99.5% 98.2% 96.8% 99.5% 98.4% 98.8% 97.6% 99.3% 98.3% 100.0% 100.0% 98.8%

50% of people experiencing first episode of psychosis to

access treatment within 2 weeks 2017/18 68% 50% 33.3% 100.0% 100.0% 100.0% 100.0% 66.7% 50.0% 100.0% 100.0% 80.0% - 82.8%

Out of Area placements for acute mental health inpatient

care - transformationQ2 2018

121.4

England

Mental Health - Care Programme Approach (CPA) - % of

patients under adult mental illness on CPA who were

followed up within 7 days of discharge from psychiatric

patient care

2017/18 98.8% 95% 98.2%99.0%

Men

tal H

ealt

h

97.3% 98.2%

110.5 149.3

Page | 6

MENTAL HEALTH – IMPROVED ACCESS TO PSYCHOLOGICAL THERAPIES (IAPT)

14. IAPT performance increased to 1.9% in March. MPFT achieved above the annualised rate of 19% by the end of the financial year. The recovery rate was above the 50% target level with a value of 56.1% in March. Additional investment is planned for IAPT in 2019/20 to meet the higher performance requirements.

15. There is now an indicator in the Mental Health Dashboard for minimising inappropriate

out of area placements.

MENTAL HEALTH – CARE PROGRAMME APPROACH (CPA)

16. As at Q3, 2018/19, 99.04% patients on CPA were followed up within 7days against the

95% standard.

MENTAL HEALTH – EARLY INTERVENTION IN PSYCHOSIS (EIP)

17. As at the end of January the CCG is achieving 80% against a target of 50%. The year to date achievement at January was 82.8%. The numbers of cases each month is small – there were no referrals in the month of February, so month on month percentage achievement is subject to variability due to small numbers.

MENTAL HEALTH – Under 25 Service 18. Progress continues to be made with implementing the agreed Improvement plan and

fortnightly reporting against this continues to be in place. A task and Finish group has been established, and held an initial meeting, to develop an improved flow of data from the provider and facilitate clearer reporting.

19. Additional staff training is being progressed and the Trust confirmed that the last locum staff will be leaving by July as permanent staff have been recruited to. This is a very positive development and the result of a lot of hard work by the provider. An issue remains with the neuro-developmental capacity within the service but both CCGs have agreed a way forward with MPFT to address this over the next few months.

Page | 7


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Trajectory

Proportion of people with a learning disability on the GP

register receiving an annual health check2017/18

51.4%

(England)

Completeness of the GP learning disability register 2017/180.49%

(England)


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Maternal smoking at delivery Q2 2018/1910.5%

(England)14%

Neonatal mortality and still births per 1,000 population 2015 4.64

Women's experience of maternity services 2015 82.1

Choices in Maternity Services


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Maintain a minimum of two thirds diagnosis rates for people

with dementia2017/18 70.2% 67% 70.1% 69.6% 69.7% 72.0% 70.3% 70.5% 70.2% 70.2% 70.6% 70.5% 70.5% 70.5%

The percentage of patients diagnosed with dementia whose

care plan has been reviewed in a face-to-face review in the

preceding 12 months

2017/1877.5%

(England)

Lear

nin

g D

isab

ility

Mat

ern

ity

6.12

(2016: CCG)

Dem

enti

a

66.2%

(2017 CCG)

Monitoring

commenced in 2016/17

88

(2017: CCG)

Reliance on specialist inpatient care for people with a

learning disability and/or autism (per million pop)

20 (per million pop) 18 (per million pop)

59 (per million pop)

64%

(2017/18: CCG)

57 (per million pop)

0.52%

(2017/18: CCG)

80%

(2017/18: CCG)

13.9% 14.3% 13.8%

Page | 8

LEARNING DISABILITIES (LD)

20. There are three indicators relating to LD:

At Q2, 2018/19, the rate for reliance on specialist inpatient care for people

with a learning disability and/or autism was reported as 57 per 1m

population. In absolute terms this is 20 patients.

The proportion of people with a learning disability on the GP register

receiving an annual health check is 64% (2017/18). The CCG has

performed above the England average of 51.4%

Completeness of the GP Learning Disability Register – the CCG performs

slightly higher than the England average.

MATERNITY

21. Three out of the four maternity indicator positions are reported annually. There are

three indicators in the dashboard, with data now populated. These show the CCG in the

middle range of the national distribution.

Maternal smoking at time of delivery is reported on a quarterly basis. Q3

(13.8%) showed a slight improvement against Q2 2018/19 performance.

DEMENTIA

22. Dementia diagnosis continues to perform above the national standard.

23. The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months, was 80% for Shropshire CCG, with the England average being 77.5% (2017/18).

Page | 9


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Achievement of milestones in the delivery of an integrated

urgent care service6 6 6 6 6 6 6 6 6 6 6 6 6

Inequality in unplanned hospitalisation for chronic

ambulatory care sensitive conditions

Q1

2018/19

2074

(England)

A&E Waiting Time - % of people who spend 4 hours or less in

A&E (SaTH)2017/18 74.6% 95% 74.9% 71.8% 74.5% 74.6% 74.8% 70.4% 70.5% 68.0% 65.5% 67.9% 66.4% 72.8% 71.0%

Trolley Waits in A&E - Number of patients who have waited

over 12 hours in A&E from decision to admit to admission

(SaTH)

2017/18 62Zero

Tolerance0 0 0 0 0 0 8 5 1 33 12 3 62

Ambulance Handover time - Number of handover delays of

>30 minutes (RSH + PRH)2017/18 6854

Zero

Tolerance424 727 681 584 590 720 867 788 1016 1076 885 639 8997

Ambulance Handover time - Number of handover delays of >

1 hour (RSH + PRH)2017/18 1655

Zero

Tolerance85 188 120 128 123 216 267 227 314 398 308 188 2562

Urg

ent

and

Em

erge

ncy

Car

e

Q1 2018/19

871

Page | 10

URGENT & EMERGENCY CARE – A&E 4 HOUR WAIT & AMBULANCE HANDOVERS

24. The SaTH A&E 4 Hour Wait target has not been achieved and is reported as 66.4% in February and 72.8% in March. This remains below the target trajectory although the March position is better than March 2018 and the best monthly performance since August 2018.

25. The action plan agreed through the A&E Delivery Board has identified 6 key action

areas:

Frailty

Stranded patients

ED Processes

Getting SAFER as standard including red to green

Capacity and demand

Working towards an integrated discharge team 26. Workforce limitations and associated systems and processes continue to be the key

problem for SaTH. The presence of some additional staff in A&E is having some beneficial impact on performance but this is in part offset by additional demand, particularly from ambulance arrivals. Investigation into the increases in ambulance demand has confirmed that there is no obvious increase in conveyances attributable to the introduction of the NHS111 service locally. The increased activity is in line with forecast trends from earlier periods. Further work is now being progressed to identify credible alternate options to conveyances and to understand the dynamics behind the increased walk–in demand.

27. This work will also focus on understanding the differing dynamics operating at PRH and

RSH in terms of demand and the nature of activity generated. The increases in both ambulance and walk-in demand are more marked at the PRH site. This work will be progressed through May with a view to identifying potential mitigating actions which may be different for the 2 CCGs. It will also include a review of admission rates at the two sites.

28. The numbers of Stranded patients appears has remained mostly below the 250 target

level since Christmas, though it has shown a tendency to drift up toward this level consistently following any sizeable reductions. Achieving flow through the hospital in terms of pre-noon discharges and providing sufficient patients for discharge to social care in a timely enough stream remains challenging. Similarly achieving a higher level of discharges in the earlier part of the week and at weekend would appear to have scope for improvement and would ease flow through each week.

29. WMAS have implemented a Strategic Capacity Cell with an objective of reducing

conveyances and diverting activity away from EDs under pressure. No formal reporting of this has yet been received but anecdotal information suggest around 150 conveyances have been diverted from SaTH since the commencement of the function at the end of February.

30. Delayed Transfers of Care also remain very low in the SATH and there has been

substantial improvement at SCHT as well. Staffing and the related patient flow issues

related to clinical decision making, however, remain very challenging which are the main

barriers to improved performance.

Page | 11

31. The existing High Impact Action plans have been reviewed with ECIST and the wider

system. This has recommended the transition of some of these into ‘business as usual’

in relation to those which focussed on developing processes and standards. Others

have been identified as needing continued work and others as being enablers to

facilitate achievement in other streams of work. Key schemes to be continued in this

context include; the work on Frail patients; improving and embedding ED systems and

processes; ambulance demand management and handover delays.

32. There was 3 x 12 hour trolley waits reported in A&E at SaTH in March. The root cause

analyses of these and the risk of harm associated with the waits are reported through

the Clinical Quality Review process with SaTH.

33. The number of ambulance handover delays in excess of 30 mins as reported by WMAS

improved in March compared to the February levels. Handover delays are still very high

however and making improvements in this has been designated as one of the High

Impact Action Areas within the A&E recovery plans. This is being picked up within the

dedicated ambulance demand task & finish group to develop a specific plan to reduce

ambulance handover delays.

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WMAS 12:04 11:50 12:03 11:42 11:23 11:41 11:48 11:50 11:49 11:34 11:42 11:50 11:47

SCCG 19:20 19:53 20:05 21:25 19:52 22:36 19:56 20:22 20:08 21:30 20:21 21:07 20:26

WMAS 20:24 21:30 22:22 23:19 21:17 21:49 21:55 23:29 22:57 22:09 22:49 21:46 22:12

SCCG 32:55 31:40 33:30 33:49 32:43 32:59 33:21 33:56 33:47 33:06 35:13 33:21 33:29

WMAS 55:17 68:13 77:02 91:17 64:32 72:40 72:43 87:19 82:57 79:50 87:31 73:04 76:14

SCCG 55:22 69:33 66:54 70:17 62:07 59:51 77:41 83:07 79:11 67:48 91:54 77:48 71:19

WMAS 92:40 122:22 128:26 136:07 102:38 125:38 123:55 142:26 120.54 125:52 123:30 109:44 120:23

SCCG 69:23 103:47 96:41 106:33 90:34 84:35 102:47 199:05 88:38 119:46 123:30 91:19 101:36

Crew Clear delays of > 30 minutes (RSH + PRH) 2017/18 4241Zero

Tolerance43 43 51 74 66 63 54 48 67 76 55 69 709

Crew Clear delays of >1 hour (RSH + PRH) 2017/18 801Zero

Tolerance0 1 2 1 1 2 2 2 0 1 1 2 15

Delayed Transfers of care attributable to the NHS (LA) 2017/18 5144Reduction

2016/17

Outturn

327 314 332 263 297 195 304 307 362 304 177 3182

DTOC Rate (SaTH) 3.5% 1.8% 1.4% 1.9% 1.8% 2.1% 1.3% 1.8% 1.4% 1.5% 1.4% 1.1% 1.1%

DTOC Rate (RJAH) 3.5% 5.3% 3.8% 4.6% 4.3% 2.9% 5.1% 6.1% 7.3% 7.1% 3.9% 5.5% 5.5%

Population use of hospital beds following emergency

admission

Q1

2018/19

500.5

(England)

36mins

90mins

New

metric

New

metric

New

metric

15mins

Category 3 (mm:ss): 90th Percentile



Q1 2018/19

418.2

Category 4 (hh:mm:ss) : 90th PercentileNew

metric180mins

Page | 13

URGENT & EMERGENCY CARE – AMBULANCE RESPONSE TIMES, CREW CLEAR AND DELAYED TRANSFERS OF CARE

34. New performance standards have been defined for the 4 categories of call and became

applicable from 1st April 2018. WMAS have reported these new measures since

September. The standards are shown below.

Call Category Standard (mean) 90th Percentile

Category 1 Mean 7 minutes 90th Percentile 15 minutes

Category 2 Mean 18 minutes 90th Percentile 36 minutes

Category 3 90th Percentile 90 minutes

Category 4 180 minutes

35. The CCG failed to meet the standards for the Category 1 calls in January but, continues

to achieve the standards for all other Call category standards. Category 1 calls account

for around 5% of total calls to the ambulance service

36. DTOC (SaTH) – In February 2019, the number of delayed days was 1.1% of occupied

bed days. This is way ahead of the 3.5% target at SaTH. The RJAH improved slightly to

5.5%, though this figure includes complex spinal patients. At SCHT, the February value

improved to 2.3%, which is a decrease from the previous month, and ahead of the target

of 3.5%.

37. Target levels for delayed transfers of care have been agreed with the Local Authority.

These are expressed as a rate per day per 100,000 population over the age of 18. The

February attainment for this was a rate of 2.6 per day per 100,000 population which is

ahead of plan.

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et Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 YTD

Patient Experience of GP Services 201883.8%

England

Last time you had a general practice appointment, how good

was the healthcare professional at giving you enough time

87%

England

(Good)


was the healthcare professional at listening to you

89%

England

(Good)


was the healthcare professional at treating you with care and

concern

87%

England

(Good)

How would you describe your experience of your GP Practice

84%

England

(Good)

Overall, how would you describe your experience of making

an appointment?

69%

England

(Good)

Were you satisfied with the type of appointment offered?

94%

England

(Good)

Primary care access - proportion of population benefitting

from extended access servicesOct-18

98.4%

(England)50% 49% 49% 51% 51% 51% 100%

Primary care workforce Mar 20181.04

(England)

Count of total investment in primary care transformation

made by CCGs compared with £3 head commitment made in

the General Practice Forward View

Qtr 2 2018Green

(England)


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RTT - incompletes (CCG) 2017/18 90.3% 92% 90.3% 90.6% 90.4% 90.6% 91.0% 91.5% 92.2% 92.2% 91.4% 90.8% 89.9% 91.0%

RTT - incompletes (SaTH) 2017/18 91.2% 92% 92.6% 93.1% 92.8% 92.6% 92.5% 92.8% 93.7% 93.2% 92.7% 91.5% 90.4% 92.6%

RTT - incompletes (RJAH) 2017/18 88.9% 92% 90.2% 89.7% 90.0% 90.3% 89.9% 90.5% 90.8% 90.6% 90.3% 90.3% 90.8% 90.2%

No. of 52 Week Waiters (CCG) 2017/18 52Zero

Tolerance10 9 9 11 8 2 0 2 4 0 0 55

Diagnostic Test Waiting Time < 6 weeks (CCG) 2017/18 0.7% 1% 1.0% 0.7% 0.7% 1.3% 1.1% 0.7% 1.0% 0.6% 0.9% 1.2% 0.8% 0.9%

Diagnostic Test Waiting Time < 6 weeks (SaTH) 2017/18 0.4% 1% 0.4% 0.4% 0.3% 0.2% 0.3% 0.2% 0.3% 0.3% 0.2% 0.7% 0.3% 0.3%

Diagnostic Test Waiting Time < 6 weeks (RJAH) 2017/18 0.5% 1% 1.2% 0.4% 0.6% 1.4% 0.9% 0.8% 1.0% 1.3% 0.9% 1.1% 1.2% 1.0%

Cancelled Operations - no. of patients re-admitted within 28

days (SaTH)2017/18 1

Zero

Tolerance1

Cancelled Operations - no. of patients re-admitted within 28

days (RJAH)2017/18 0

Zero

Tolerance0

Elec

tive

Acc

ess

0 0 1 0

0 0 0 0

Prim

ary

Me

dic

al C

are

91% Good

92% Good

92% Good

89% Good

1.09

(March 2018)

Green

88.6%

76% Good

2018 GP

Patient

Survey

96% Good

Page | 15

PRIMARY MEDICAL CARE

38. Access to, and satisfaction with, Primary care services continues to be rated highly by

Shropshire patients and compares well with the overall England position.

39. Extended access at weekends and evenings was introduced from the 1st of October and

is reported to be operating smoothly.

40. Comparing the CCG with others in nationally published data, continues to show the

Shropshire practices, in general, are rated at the positive end of the national spectrum

on almost all available measures.

ELECTIVE ACCESS – 18 WEEKS RTT, 52 WEEK WAITERS, AND < 6 WEEKS

DIAGNOSTICS

41. The CCG failed to achieve the RTT 18 week performance in February (89.9%).

42. SaTH failed to achieve their overall RTT target in February at 90.4%. This continues to be as a result of bed pressures and escalation into both Day Surgery Units (DSUs). At the time of writing this report the situation has not improved and the risk to RTT delivery remains high. The Planned Care Working Group has escalated concerns upwards and this will be taken to the next Strategic Commissioning Board with SaTH.

43. RJAH have achieved 90.8% in February which is under target. Unofficial figures from the Trust has indicated however that the target was achieved in March 2019.

44. At the end of February there were 0 x 52 week waiters reported for the CCG which is

ahead of the trajectory agreed with NHSE. RJAH have confirmed to the CCG that they had zero x 52 week waiters at the end of March for Shropshire CCG patients.

45. CCGs are also monitored on the overall numbers on the Incomplete Waits list to remain at the March 2018 level. The CCG will not achieve this at the end of March 2019. The target achievement will be carried forward into the 2019/20 year. The number of incompletes at the end of February 2019 was 19,057 compared to the March 2018 target level of 17,708

46. Performance against the 99% standard for waiting time for a Diagnostic Test was achieved by the CCG in February with a level of 99.2%.

47. Cancelled Operations – both SaTH and SCHT failed the target in Q3 with 1 cancellation each. This is expected to continue into Q4 as a result of continued bed pressures although every effort is made to reschedule any cancelled within 28 days.

Page | 16


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Percentage of NHS Continuing Healthcare full assessments

taking place in an acute hospital setting

Qtr 2

2018

12.34%

(England)


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Healthcare acquired infection (HCAI) measure (MRSA) 2017/18 0 0 0 0 0 0 0 0 1 0 0 0 0 2 3

Healthcare acquired infection (HCAI) measure (Clostridium

difficile infection)2017/18 62 73 6 4 3 3 5 4 4 4 2 2 3 6 46

E coli bacteraemia 2017/18 232 205 17 18 17 36 23 21 36 25 19 15 27 25 279

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Page | 17

NHS CONTINUING HEALTH CARE (CHC)

48. The % of NHS Continuing Health Care full assessments taking place in an acute

hospital setting. The CCG reported 5.56% for Q2 2018/19, which is below the England

average of 12.34%

HEALTH ACQUIRED INFECTION MRSA AND CDIFF

49. For 2018/19 there have been 3 incidences of MRSA reported at CCG level.

50. C Difficile – for 18/19, 46 cases were reported at CCG level.

51. At the end of 2018/19, E Coli infections are above target. The anonymised data of

these cases will be analysed and shared with the Local Health Economy E coli BSI

Reduction Group and the Local Health Economy IPC Group to identify opportunities and

potential interventions to reduce the risk of E. coli BSI in the CCGs population.

NHS 111

52. NHS111 activity has stabilised into a more predictable pattern following the transfer from

Shropdoc. For the CCG in January the rate of disposition of the calls to the ambulance

service and to ED were 13% and 6% respectively.

53. These disposition rates appear similar to other CCGs in the region. In terms of useage

of NHS111 by population size, Shropshire is in the middle of the range of CCGs though

Telford and Wrekin show significantly higher rates of calling NHS111 than most other

local CCGs.

RECOMMENDATIONS

54. The Governing Body is asked to NOTE the contents of the report and the CCG actions

contained within to recover performance in those areas which are currently below target.

1



Elective Care - Waiting Time Management


Dr Julie Davies – Director of Performance & Delivery


Charles Millar – Head of Performance, Planning and BI

Presenter:

Dr Julie Davies - Director of Performance & Delivery

Purpose of the report: To inform the Board around the CCG’s performance around managing elective waiting times.

Key issues or points to note: The count of numbers of people waiting for treatment exceeds the baseline at February but has decreased slightly in the last two months. The 18 week wait target of 92% was not achieved in February being 89.9%. The number of 52 week waiters was 0 in February which is ahead of the planned trajectory.

Actions required by Governing Body Members: To note the contents of the report

2

Monitoring form Agenda Item: GB-2019-05.068


1 Additional staffing or financial resource implications Yes/No If yes, please provide details of additional resources required

2 Health inequalities Yes/No Achievement of the RTT target ensures at least 92% patients are treated within

the nationally mandated target of 18wks.

3 Human Rights, equality and diversity requirements Yes/No If yes, please provide details of the effect upon these requirements



6 Risk to financial and clinical sustainability Yes/ No If yes how will this be mitigated

3

NHS Shropshire CCG

Elective Care – Waiting Time Management

Charles Millar - Head of Performance Planning and BI

Executive Summary and Actions Required

The CCG, at February, is not achieving against the objective of keeping the count of patients waiting below the value at March 2018. A small reduction in the numbers waiting has been seen between December and February.

The CCG is below the 18 week wait target standard;

The number of 52 week waiters was 0 in February and the CCG continues to manage the position successfully.

Introduction 1 This report summarises the CCG’s position in managing waiting times

for patients and the actions being taken to minimise this within the resources available.

2 The target for CCGs is to have no more patients waiting for definitive

treatment than at March 2018 and to reduce the number of 52 week waiters by 50% from the March 18 position.

3 All CCGs are required by NHSE to provide a Board level reporting summarising progress and actions to achieve these.

Detail Overall Numbers Waiting 4 Based on NHS waiting time figures (RTT), in March 2018 there were

17,708 patients waiting for treatment. At the end of February 2019 this had changed to 19,057. This is 7.6% above the baseline level but is 171 below the December count.

5 The change to February is made up of an increase at SaTH and out of

county providers and a decrease at RJAH. 6 The increase in numbers at SaTH has been raised at formal meetings

and is being impacted by reduced capacity over the winter months alongside increases in demand and increased cancer referrals. Some displacement of routine activity is taking place due to the need to accommodate more urgent cancer treatments.

4

7 Reductions in numbers at RJAH are benefitting from an improved position with respect to backlogs within the SOOS service.

8 RJAH and SaTH have both agreed adjustments to their target numbers to reflect the expansion of SOOS (RJAH) and re-opening of some services to referrals at SaTH. These do not provide any gain to the CCG as the patients would have been recorded with other providers anyway.

9 Currently the CCG is forecasting an outturn at the end of March around 18,800 Incomplete waiters. Allowance is being made in the planned activity in 2019/20 to recover this number back to the required level to equate to the March 2018 level.

Waiting Time Standards 18 week standard 10 At February 2019, the CCGs overall performance on this measure was

89.09% of patients waiting less than 18 weeks for definitive treatment against the target level of 92%. This is a deterioration from December’s figure.

11 This is made up of 90.2% at SaTH, 92.8% at RJAH and 86.6% at the

aggregate of all other providers. Overall as a provider, SaTH are achieving 89.7% and RJAH 90.5%. There is a recovery trajectory agreed at RJAH which shows them achieving 92% at the end of the financial year.

12 Waiting time standards for the CCG’s patients have generally been achieved throughout the year at the local providers but the aggregate for the out of county providers is below the standard. The data shows, however, that the performance at these providers for the CCG’s patients is very close to that of the providers overall performances and that consequently the poorer RTT performance is a systemic feature for these providers. The CCG attends contract meetings with the key out of county providers on a regular basis to ensure local issues are raised.

52 week waiters 13 NHSE has required all CCGs to manage long waiters proactively

through ensuring that any over 52 week waiters have clear plans at the current provider Trust or are offered an option of having treatment elsewhere.

14 At the end of February the CCG had no patients waiting over 52 weeks.

This is well ahead of the agreed trajectory.

5

15 The CCG has a weekly process of confirming numbers waiting with provider Trust and obtaining assurance that clear plans are in place or that alternate choice has been offered to these patients.

Recommendations 15 The Board is requested to note the contents of the report

Agenda Item: GB-2019-05.069 Governing Body Meeting: 8.05.19


Ambulance Demand Deep Dive Analysis Report




Emma Pyrah, Head of In Hospital Commissioning

Presenter:


Purpose of the report: The purpose of this report is to provide the Governing Body with a briefing on the key findings from the first phase of the deep dive analysis into the increase in ambulance demand reported in 2018/19 and the next steps.

Key points to note:

Over the last 12 months, and particularly this winter, Shropshire and Telford & Wrekin have recorded higher than expected increases in ambulance demand. Whilst increases have been experienced across the region, our local demand increases are higher than elsewhere.

The new multi-stakeholder Ambulance Demand and Pathways Group has led on a deep dive analysis of ambulance activity to determine the nature of the increase and identify the key drivers for that.

The key findings from the first phase of analysis have been reported to A&E Delivery

Group/Board and are set out in this report. The deep dive has established that:-

o In Winter 2018/19 WMAS reported that Shropshire and Telford & Wrekin were 8%

above contract compared with a 2.55% average for the Region.

o The majority of the 11% increase in A&E attendances in 2018 compared to 2017 relates to a) walk in activity b) the out of hours period and c) PRH in particular. 70% of the ambulance generated A&E growth was in the out of hours period.

o At this stage, no direct causal link can be established between this increase in

ambulance demand and any changes in service delivery locally although some work remains ongoing in relation to any potential impact of the change in the GP OOH service delivery model.

o The increase in ambulance demand appears to be a continuation of a growth trend

line reported before the GP OOH telephone number switched to NHS111 in July

2018. The key material impact the switch of NHS111/GP OOH number has had is to change the proportional split of ambulance demand by source, with an increase in dispositions from 111 and a reduction from 999.

o The NHS111 Clinical Assessment Service is contributing to ambulance demand reduction with two thirds of all cases being downgraded to an alternative to ambulance dispatch. Further work is needed to understand why only two thirds of Cat 3 & 4 cases are going through this service.

o The highest volume (25%) of ambulances arrive at SATH in the 4 hour period between 2pm and 6pm which not unsurprisingly corresponds with the highest volume of over 1 hour ambulance handover delays.

o Almost half the ambulance conveyances to SATH were discharged rather than admitted which indicates that their clinical needs/acuity were relatively low and could potentially have been managed through alternative pathways to acute. Further work is underway to determine what types of services outside of acute are needed to manage this activity.

o The new WMAS Strategic Capacity Cell has the potential to positively impact on reducing ambulance demand but it is in its infancy and requires time to bed in and also requires viable alternatives to conveyance to SATH to be available locally if it is to deliver its full impact.

Actions required by the board/committee: The Governing Body are recommended to:-

Note the contents of this briefing report and the next steps being taken.

Request a further update on progress following the completion of the next phase of analysis and action planning.






4 Clinical engagement Yes There are clinical members of the Ambulance Demand and

Pathways Group

5 Patient and public engagement Yes There is a patient representative on the Ambulance Demand and

Pathways Group

6 Risk to financial and clinical sustainability Yes The second phase of this work is to identify the root causes of the

increases in A&E demand and then agree actions to provide alternatives to better manage this demand and thereby reduce the pressure on the already challenged acute and ambulance services and the associated costs.

REPORT TO GOVERNING BODY – 8TH MAY 2019

AMBULANCE DEMAND DEEP DIVE ANALYSIS REPORT Purpose of the Report 1. The purpose of this report is to provide the Governing Body with a briefing on the key

findings from the first phase of the deep dive analysis into the increases in ambulance demand reported in 2018/19 and set out the next phase of work.

Introduction 2. Over the last 12 months, and particularly this winter, Shropshire and Telford & Wrekin

have recorded higher than expected increases in ambulance demand. Whilst increases have been experienced across the region, our local demand increases are higher than elsewhere.

3. A new commissioner led system multi-stakeholder Ambulance Demand and Pathways

Group was established in January 2019 which has led on the analysis of ambulance demand. The first phase of the deep dive analysis is complete and the key findings have been reported to A&E Delivery Group/Board.

4. In determining the key drivers for ambulance demand increases, the analysis has

included triangulation with some of the key local system changes that have occurred in the last 12/18 months that could have impacted including the NHS111/GP OOH number switch.

Key Findings 5. Ambulance activity for Shropshire and Telford & Wrekin in Winter 2018/19 was reported

by WMAS as being 8% above contract compared to 2.55% for the Region as a whole despite there being 4% growth included in the contracted WMAS activity levels.

6. There has been an 11% (n=11,872, c228/week) increase in A&E attendances at SATH in

2017 compared to 2018, 59% of this increase was at PRH (c134/week). The majority of the recorded growth was generated in the out of hours period (57.6%).

A&E All attendances

Jan – Dec 2017

Jan – Dec 2018

Year on year variance

% variance

In hours 49,500 54,525 5,025 10.1%

Out of hours 57,717 64,564 6,847 11.8%

7. Analysis of the proportional split of this A&E activity demand growth by source indicates

the majority (63.2%) is ‘walk in’ with only just over a third 36.5% (n=4,332, 83/week) being ambulance generated.

8. 70% of the ambulance generated A&E growth was in the out of hours period and was the highest at PRH. Further analysis is required to map any impact the change in the GP OOH model in October 2018 may have had on ambulance demand in this period. This work is underway in partnership with Shropshire Community Health NHS Trust who have held the GP OOH contract since 1st October 2019.

SATH A&E arrivals by ambulance by site – comparison 2017 to 2018

RSH Jan – Dec 2017

Jan – Dec 2018


% variance

In hours 6437 6985 548 8.5%

Out of hours 10354 11761 1407 13.6%

PRH Jan – Dec 2017

Jan – Dec 2018


% variance

In hours 7301 8067 766 10.5%

Out of hours 10882 12493 1611 14.8%

9. Comparing the ambulance growth reported in the last 12 months compared to the growth

trend line in previous years shows that the growth in 2018/19 is similar to the levels of demand which would be expected purely from a continuation of the upward trend recorded in previous years. Although the switch of the NHS1111/GP OOH number occurred in July 2018 the analysis could find no material causal relationship between this change and there being a step change in ambulance demand.

10. Conveyance rates have remained relatively static and consequently, based on this data,

increased conveyances are a product of the overall increased ambulance demand.

11. Since the NHS111/GP OOH switch, NHS111 reported call volumes have increased by an average of 106% (c6,000 calls per month). This post switch total NHS111 call volume is, however, similar to the combined pre-switch total activity for both services so does not represent a material increase in total demand.

12. The national NHS111 KPI for ambulance dispositions is 11%. Both pre and post

number switch the local average 111 ambulance disposition rate has remained relatively static and close to the 11% KPI target and in line with the regional average.

13. The NHS111 Clinical Assessment Service (CAS) is designed to re-triage Cat 3 & 4

ambulance dispositions but measuring impact has not been possible at a CCG level as the data is only currently reported at a regional level. Regional figures indicate that 61% were directed to a clinician in the CAS for re-triage and 64% of these were downgraded from ambulance dispatch as a result. This indicates that the CAS is impacting on

111/GP OOH

number switch

ambulance demand reduction, however, further work is required with the regional commissioner to understand why all Cat 3&4 cases are not going through the CAS.

14. The most significant rise in ambulance activity has been in Category 2 this year

(response standard 18 minutes mean, 90% of cases 36 minutes). Category 2 and 3 increases are mainly caused by the additional 111 generated ambulances.

15. The key material impact the switch of NHS111/GP OOH number has had is to change

the proportional split of ambulance demand by source, with an increase in dispositions from 111 and a reduction from 999. These changes are not unexpected as before the switch the GP OOH ambulance dispositions would have been recorded as being generated via 999 and are now going through 111. This increase is more marked on PRH. A contributory factor could be that Telford & Wrekin have the highest usage of NHS111 per 1000 head of population in the region (T&W Rank 1: 36/1000, Shropshire Rank 9: 26/1000).

16. The highest volume (25%) of ambulances arrive at SATH in the 4 hour period between

2pm and 6pm. This not unsurprisingly corresponds with the time period when SATH report the highest number of over 1 hour ambulance handover delays (32%). Key pressure point hours of ambulance demand on SATH appear to be caused mainly by 999 generated cases rather than NHS111.

17. The introduction of the new WMAS Strategic Capacity Cell (SCC) in February 2019 has

the potential to support with diversion from conveyance but this service is in its infancy with only March’s data currently available which indicates Shropshire/ Telford accounts for only 7.9% (115) of the cases where an alternative outcomes to conveyance was achieved. This data is the first month only and therefore should be taken as indicative at this stage as the SCC beds in however it would appear that use or availability of alternative community pathways is very low locally.

18. Both acute hospital sites have recorded a similar increase in activity on Thursdays during

January. The impact has come from both NHS 111 and direct 999 cases alike. The increase is mainly during GP opening hours. There has also been an increase in cases received on Sundays which appears to be generated from NHS 111.

19. During the 15 months Oct 17 to Jan 19, there were 24,095 ambulances to RSH and

26,477 ambulances to PRH. Almost half of these ambulance arrivals were discharged rather than admitted. Further review of A&E data suggests that 24% of cases discharged from PRH and 13% of cases discharged at RSH have no treatment/ investigations or advice only. This indicates that there is potential for a proportion of these cases to be managed through alternative pathways to acute and the ambulance group is undertaking further work to determine if there are viable alternatives which could be put in place, where possible using the learning from other areas.

20. The Ambulance Demand and Pathways Group is now completing the further elements of analysis referenced in this paper and developing an action plan from its findings.

Recommendation 21. The Governing Body are recommended to:-

20.1 Note the contents of this briefing report and the next steps being taken.

20.2 Request a further update on progress following the completion of the next

phase of analysis and action planning.

1



Single Strategic Commissioner for Shropshire & Telford &

Wrekin


David Stout, Accountable Officer, Shropshire CCG

David Evans, Accountable Officer, Telford & Wrekin CCG


Sam Tilley, Director of Corporate Affairs, Shropshire CCG

Alison Smith, Executive Lead Governance & Engagement,

Telford & Wrekin CCG

Presenter:



Purpose of the report: The purpose of this report is to gain agreement from the Governing Body on future working arrangements for Shropshire and Telford and Wrekin CCGs

Key issues or points to note: In November 2018 NHS England (NHSE) set a new running cost savings target of 20% for CCG’s to attain by the end of the financial year 2019/20 Following this announcement in January 2019, the NHS Long Term Plan was published setting out key ambitions for the service over the next 10 years. The long term plan included the requirement to streamline commissioning organisations with typically one commissioner for each STP/Integrated Care System. In response to these announcements and with NHSE support, Shropshire CCG and Telford & Wrekin CCG carried out separate facilitated sessions and then a joint session early in 2019 to begin exploring the appetite for and mechanisms required to support closer working. These sessions were positively received and resulted in a firm a commitment to explore the formation of a strategic commissioning organisation to cover the entire country. This report sets out a proposal for Shropshire CCG and Telford & Wrekin CCGs regarding future working arrangements within the context of the likely changes to the NHS landscape in the next few years and NHSE’s requirements regarding running cost savings.

Actions required by Governing Body Members: The Governing Body is asked to:

Support the dissolution of both CCGs and the formation of a single strategic commissioning organisation for the Shropshire, Telford & Wrekin footprint.

Agree to the early recruitment of a single Accountable Officer and the early integration of management teams.

Support a timetable for the formation of the single strategic commissioning organisation by April 2020

Support the development of a Programme Management Office to oversee the programme.

2



1 Additional staffing or financial resource implications Yes Future working arrangements will impact on future resources required by the

CCG’s



4 Clinical engagement Yes Clinical engagement will be key in moving forward with and shaping future

working arrangements

5 Patient and public engagement Yes It is likely that some form of engagement with the populations of both Shropshire

and Telford and Wrekin CCGs will be required. If the proposed change is viewed as substantial by the Joint Health Overview and Scrutiny Committee then this will require a formal consultation process that will need resourcing.

6 Risk to financial and clinical sustainability Yes Future working arrangements are a key consideration in the financial and clinical sustainability of the CCG’s going forwards

3

Shropshire CCG Governing Body Meeting 2019

Single Strategic Commissioner for Shropshire & Telford & Wrekin



Introduction 1. The NHS is now in a period of transition with new emerging concepts of the role

of commissioner and provider organisations. CCGs must respond flexibly to the new landscape and consider where best to focus clinical and managerial leadership and how they can adapt and interface with their local Sustainability and Transformation Partnership to transform into a commissioning organisations fit for this future. The recently published NHS Long Term Plan reinforces this direction of travel.

2. In addition CCGs have been tasked with making 20% reductions in their running costs by the end of the financial year, 2019/2020.

3. This report makes a recommendation for the future configuration of Shropshire and Telford & Wrekin CCGs in this context.

Report 4. With NHS England (NHSE) support, Shropshire and Telford & Wrekin CCGs carried out

separate facilitated sessions and then a joint session early in 2019, to begin exploring the appetite for and mechanisms required for closer working. These sessions were positively received and resulted in a commitment to explore this further, including the formation of a new single strategic commissioning organisation.

5. In order to ensure it is fit for purpose, remains efficient and effective and can best serve its population, Shropshire CCG must consider the most appropriate organisational form for strategic commissioning going forward. Discussions have included both options of closer working; informal working using joint management and collaborative mechanisms whilst still retaining two statutory bodies and the alternative of dissolving the two CCGs and creating one new strategic commissioning organisation.

6. To meet the 20% reduction in running costs*, the total reduction in allocations between 2018/19 and 2019/20 is £1.218m across both CCG’s (£0.775m Shropshire and £0.443 for T&W). Although the first option has some benefits, it was felt that the efficiencies both CCGs could achieve by stripping out all the duplication of effort, time and staff resource currently used to commission services and oversee contractual performance of the same providers would not be fully realised, as some duplication will still remain.

The ‘20%’ reduction quoted in the NHSE guidance is based on comparing 2019/20 allocations to

2017/18 outturns adjusting for pay awards , pension changes etc. and assumes that the CCGs are

operating within their running cost allocations.

4

7. The conclusion of these discussions has been that the second option of dissolution of both CCGs and the creation of a new strategic commissioning organisation across the whole footprint of Shropshire, Telford and Wrekin will realise the following benefits:

It will immediately respond to the requirements set out in the NHS Long Term Plan for one strategic commissioner per STP area by allowing both CCGs to redesign a new organisation that will have the right capacity and capability to commission at a strategic level and also at a more local ‘place’ level.

It will allow duplication of staff time that is currently used to contract and oversee performance to be focused on other commissioning priorities, i.e. health inequalities/prevention.

By reducing duplication both CCGs will be well placed to reach the 20% running cost target set by NHS England.

Although creating uncertainty for staff in the short term, this option will provide a more sustainable future for our staff in the long term.

8. The Governing Body is therefore asked to support the creation of a single strategic

commissioner for the Shropshire, Telford and Wrekin footprint.

9. Discussions have taken place with NHS England (NHSE) regarding the considerations for the CCG’s in order to make this happen and NHSE have recently published new guidance entitled “Procedures for Clinical Commissioning Groups to apply for Constitution change, merger or dissolution” which are attached at Appendix 1.

10. In moving towards the creation of a single strategic commissioning organisation the following key elements must be considered:

Timeline – NHS England’s new guidelines have relaxed the timescales for applications to bring commissioning organisations together. Applications must now be made by 30 September preceding the April in which the change would take effect. It is proposed that the CCG support an application by 30 September 2019 with a view to a new strategic commissioning organisation taking effect on 1 April 2020.

Whilst it is acknowledged that there is a significant amount of work involved in the planning, preparation and implementation of this, so far as it is possible, it is also considered that it would be most beneficial to all stakeholders, both internal and external, that this process is managed expeditiously, preferably to conclude for 1 April 2020. Recruitment of a single Accountable Officer – A key step in forming a single strategic commissioning organisation will be the recruitment of a single Accountable Officer early in the process to oversee its development. This should also include the early integration of the CCGs management teams. Resources – In line with NHSE guidance the CCGs will need to create a Programme Management Office (PMO) to oversee what will be a significant change programme. Updates – regular updates will be required by the Governing Body as the process is developed.

5

Recommendations The Governing Body as asked to:

Support the dissolution of both CCGs and the formation of a single strategic commissioning organisation for the Shropshire, Telford & Wrekin footprint.

Agree to the early recruitment of a single Accountable Officer and the early integration of management teams.

Support a timetable for the formation of the single strategic commissioning organisation by April 2020

Support the development of a Programme Management Office to oversee the programme.

Procedures for clinical commissioning groups to apply for constitution change, merger or dissolution

NHS England and NHS Improvement

OFFICIAL

2

NHS England INFORMATION READER BOX

Directorate

Medical Operations and Information Specialised Commissioning

Nursing

Finance

Trans. & Corp. Ops. Commissioning Strategy

Publishing approval number: 000441

Document Purpose Guidance

Document Name Procedures for clinical commissioning groups to apply for constitution

change, merger or dissolution

Author NHS England, CCG Assessment team

Publication Date April 2019

Target Audience CCG Clinical Leaders

Additional Circulation

List

NHS England Regional Directors, NHS England Directors of

Commissioning Operations

Description Policy and procedures to be followed by clinical commissioning groups

(CCGs) and NHS England in the circumstances of a CCG wishing to

apply to make changes to its constitution or to dissolve or two or more

CCGs wishing to apply to merge

Cross Reference N/A

Superseded Docs

(if applicable)

Procedures for clinical commissioning group constitution change,

merger and dissolution – Nov 2016; first published October 2015

Action Required To note

Timing / Deadlines

(if applicable) N/A

Contact Details for

further information

Assessment team

[email protected]

Document Status This is a controlled document. Whilst this document may be printed, the electronic version posted on

the intranet is the controlled copy. Any printed copies of this document are not controlled. As a

controlled document, this document should not be saved onto local or network drives but should

always be accessed from the intranet.


OFFICIAL

3

CCG Improvement and Assessment Framework 2018/19: Technical Annex

Version number: 0.3

First published: October 2015

Prepared by: NHS England assessment team

Classification: OFFICIAL

This document can be made available in alternative formats, such as easy read or large

print, and may be available in alternative languages, upon request. Please contact 0300

311 22 33 or email [email protected]


OFFICIAL

4

Contents

Contents ..................................................................................................................... 4

1 Preface to the revised edition – April 2019 ......................................................... 5

2 Introduction ......................................................................................................... 5

3 Equality statement .............................................................................................. 5

4 Procedure to change a CCG constitution ........................................................... 5 4.1 Background ............................................................................................. 5 4.2 Application process to be adopted .......................................................... 6 4.3 Consideration by NHS England of the proposed variation....................... 7

5 Procedure to agree a CCG merger ..................................................................... 9 5.1 Background ............................................................................................. 9 5.2 Roles and resposibilities .......................................................................... 8

5.3 Criteria for merger ................................................................................. 10 5.4 Pre-application activity and the merger application ............................... 11

6 Procedure to dissolve a CCG ........................................................................... 12 6.1 Background ........................................................................................... 12

6.2 Application process to be adopted ........................................................ 12 6.3 Consideration by NHS England of the proposed dissolution ................. 13

Annex 1: Checklist for constitution changes ............................................................. 15

Annex 2: Legal requirements of a CCG constitution ................................................. 16

Annex 3: Merger application requirements ............................................................... 17

5

1 Preface to the revised edition – April 2019

1. This document has been revised from the previous version (November 2016) following

publication of the NHS Long Term Plan in January 2019. The Long Term Plan describes how the commissioning system will continue to evolve and sets out the intention that by April 2021 all of England will be covered by an Integrated Care System, involving a CCG or CCGs working together with partners to ensure a streamlined and single set of commissioning decisions at system level. Some CCGs will want to merge to facilitate this streamlined and integrated commissioning approach, and those considering merger are encouraged to discuss their plans with their regional team, which will provide further advice and guidance.

2 Introduction

2. These procedures are to be followed by CCGs and NHS England. They are

underpinned by the requirements of the National Health Service Act 2006 (as amended) (referred to from now on as ‘the Act’) and by relevant regulations.

3. Under the Act, NHS England has powers to make transfers of property and staff

in connection with variation, merger, or dissolution. The use of these powers is included in the scope of these procedures.

4. NHS England has separate powers which allow it to vary a CCG’s area or membership without an application from the CCG. The application of this power is out of scope of the procedures outlined in this document.

3 Equality statement

5. NHS England has a duty to have regard to the need to reduce health inequalities in access to health services and health outcomes achieved as enshrined in the Act. NHS England is committed to ensuring equality of access and non-discrimination, irrespective of age, gender, disability (including learning disability), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex (gender) or sexual orientation.

6. In carrying out its functions, NHS England will have due regard to the different

needs of protected equality groups, in line with the Equality Act 2010. This document is compliant with the NHS Constitution and the Human Rights Act 1998. This applies to all activities for which they are responsible, including policy development, review and implementation.

4 Procedure to change a CCG constitution

4.1 Background

7. Every CCG must have a constitution. This is a key document for each CCG that sets out various matters including the arrangements that it has made to discharge its functions and those of its governing body; its key processes for decision

https://www.longtermplan.nhs.uk/online-version/

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making, (including arrangements for ensuring openness and transparency in the decision making of the CCG and its governing body) and arrangements for managing conflicts of interest.

8. NHS England must be satisfied that the constitution complies with the

requirements of the Act and is otherwise appropriate. Guidance is available to CCGs here.

9. Section 14D of the Act provides that where NHS England grants an application

for establishment, a CCG is established, and the proposed constitution approved under the application process has effect as the CCG’s constitution. This means that it is the constitution assessed as part of CCG authorisation that is the constitution on which establishment is based. Any change to the constitution used at authorisation needs to be agreed with NHS England.

10. Section 14E of the Act provides for applications for variation of constitutions.

Under section 14E, a CCG may apply to NHS England to vary its constitution (including doing so by varying its area or its list of members). If NHS England grants the application, the variation to the constitution will come into effect.

11. Under section 14J, a CCG must publish its constitution. If the constitution is

varied, whether on the request of the CCG or under the powers of NHS England, the CCG must publish the revised constitution. This should be done as soon as is reasonably practical after the CCG receives the relevant approval or decision from NHS England. No requested changes to the constitution can be acted upon until formal approval has been received.

12. NHS England regional teams should be notified of any significant changes, for

example, to the leadership of a governing body. Where CCGs are wishing to make significant changes, such as a replacement of the chair of the governing body, any new member, should be subject to a selection process of equivalent rigor as the original member. This will ensure that the new member has the capability to fulfil the role.

13. Section 14A(1) of the NHS Act 2006 requires each provider of primary medical

services to be a member of a CCG. As new models of care are developed CCGs should therefore ensure that their membership reflects this and that any amendments this requires to their constitution are made.

14. The CCG’s constitution will need to reflect any arrangements for joint and delegated commissioning arrangements. In Annex C of the document Next steps towards primary care co-commissioning there is a suggested form of words for joint commissioning constitutional amendments, which can be tailored to individual circumstances. CCGs with delegated commissioning must have a committee to manage the delegated functions and to exercise the delegated powers.

4.2 Application process to be adopted

15. Other than in the circumstances set out in paragraph 16 below, NHS England will consider applications for the variation of constitutions throughout the year. CCGs considering changes to constitutions are advised to discuss their proposed application with the relevant NHS England regional team at an early

https://www.england.nhs.uk/wp-content/uploads/2018/10/supporting-notes-model-constitution-v1.2.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/nxt-steps-pc-cocomms.pdf

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stage in advance of submission.

16. Any application for variation which will change a CCG’s boundary, or its list of members, must be made by 30 June so that the change can be reflected in the allocations for the following financial year. Any boundary change will take effect from 1 April of the following year.

17. Applications requiring boundary changes should list the Lower Super Output

Areas (LSOA) codes, and for any proposed practice moves the application should include relevant practice codes. In addition, applications should provide the regional team with a map of proposed changes to ensure that the area remains appropriate.

18. The application should come from the CCG and changes to the constitution made

in tracked changes for ease of review by the regional team. The application should already have been discussed and agreed with CCG member practices and stakeholders should have already been consulted at the point of submission of the application.

19. The application should consist of:

a. the reason why a variation is being sought;

b. the proposed varied constitution with the amended clauses clearly signposted;

c. assurance that member practices have agreed to the proposed change(s);

d. assurance that stakeholders have been consulted if required;

e. a self-certification by the Chair or Accountable Officer, on behalf of the CCG, that the revised constitution continues to meet the requirements of the NHS Act 2006;

f. assurance that the CCG has considered the need for legal advice on the implications of the proposed changes, including whether advice has been sought; and

g. a complete impact assessment of the changes, which should cover as a minimum the factors required to be considered by NHS England set out below.

20. A checklist of requirements for constitution changes can be found at Annex A. A list of legal requirements for a CCG constitution can be found at Annex B.

21. NHS England may seek clarification or additional information during the period

when it is considering applications.

4.3 Consideration by NHS England of the proposed variation

22. The Act and the National Health Service (Clinical Commissioning Groups) Regulations 2012 set out the factors which NHS England must consider when considering an application under this procedure. They are:

a. that the constitution meets the requirements of legislation and is otherwise appropriate;

b. that each of the members of the CCG is a provider of primary medical services;

c. that the area is appropriate (i.e. that there are no overlapping CCGs and no gaps);

http://www.legislation.gov.uk/uksi/2012/1631/contents/made

http://www.legislation.gov.uk/uksi/2012/1631/contents/made

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d. that the proposed Accountable Officer is appropriate; e. that the CCG has made appropriate arrangements to ensure it is able to

discharge its functions; f. that it has made arrangements to ensure that its governing body is

correctly constituted and otherwise appropriate; g. the likely impact of the requested variation on the persons for whom the h. CCG has responsibility i.e. the registered and resident population of the

CCG; i. the likely impact on financial allocations of the CCG and any other CCG

affected for the financial year in which the variation would take effect;

j. the likely impact on NHS England’s functions;

k. the extent to which the CCG has sought the views of the following, what those views are, and how the CCG has taken them into account:

o any unitary local authority and/or upper tier county council whose area covers the whole or any part of the CCG’s area;

o any other CCG which would be affected; and o any other person or body which in the CCG’s view might be affected

by the variation requested. l. the extent to which the CCG has sought the views of patients and the

public; what those views are; and how the CCG has taken them into account; and

m. how often the CCG has applied for variations of the kind requested.

23. In addition to these factors, NHS England will consider, where appropriate, how any boundary change will fit with the local Sustainability and Transformation Partnership (STP) or Integrated Care System (ICS), and will consider the CCG’s performance, as determined by its annual NHS England assessment.

24. It is for the CCG to determine what information, in addition to the requirements set out in the previous section, should be submitted to help NHS England decide on the application for constitution change. NHS England may ask for clarification or additional information it may require at any stage. Additionally, NHS England may consider any other material in making its decision which it considers relevant, not just the material submitted by the CCG. At all stages the procedure will involve communication between NHS England and the CCG.

25. NHS England will acknowledge all applications for variations within two weeks of receipt and will notify the CCG in writing of the outcome of its decision within eight weeks.

26. If NHS England thinks that its statutory duties in relation to CCGs make it

preferable for it to do so, it may: a. where granting the application would have a significant impact on

allotments to the CCG in question or other CCGs, defer determination of the application until the later of the end of the financial year in which it was received and the date six months after it was received; or

b. defer determination until it has received all related applications for establishment or variation from other CCGs.

27. There is no appeal or review process to NHS England’s decision.

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5 Procedure to agree a CCG merger

5.1 Background

28. The NHS Long Term Plan describes how the commissioning environment will continue to evolve and it is in this context that CCGs will operate in future.

29. Building on the progress already made, the NHS Long Term Plan sets out an intention

for Integrated Care Systems (ICSs) to cover the whole country by April 2021. It states

that: ‘Every ICS will need streamlined commissioning arrangements to enable a single

set of commissioning decisions at system level… CCGs will become leaner, more

strategic organisations that support providers to partner with local government and other

community organisations on population health, service redesign and Long Term Plan

implementation.’

30. By 2020/21, individual CCG running cost allowances will be 20% lower in real terms than in 2017/18 and CCGs may therefore wish to explore the efficiency opportunities of merging with neighbouring CCGs.

31. There are provisions under section 14G of the Act allowing for mergers of CCGs, with

specific requirements set out in the CCG Regulations 2012. CCGs have a legal right to apply for a merger and there are specific legal factors and further criteria that NHS England will consider when deciding whether to agree the merger. These criteria are set out in section 5.3.

5.2 Roles and responsibilities

32. The process to merge two or more CCGs will require the commitment and leadership of

the existing CCGs’ governing bodies. The existing CCGs will need to direct sufficient resources to the merger, including establishing a programme management office (PMO), in recognition that this is a significant change programme. However, the merger should not unduly distract the existing CCGs from business as usual, including delivering core performance standards and achieving financial balance.

33. NHS England will provide information and guidance to CCGs considering merger and will assess the suitability of proposed mergers.

34. NHS England has a statutory duty to authorise any new CCG and will make reasonable

requests for information and assurances from the existing CCGs to do so. 35. Following conditional authorisation, NHS England will require reasonable assurance on

progress from the existing CCGs throughout the merger preparation process to ensure that all necessary action has been taken to confirm the establishment of the new CCG. NHS England will continue to provide existing CCGs with support and guidance through the merger preparation process, including working with other partners, notably NHS Shared Business Services (SBS) on financial matters and NHS Digital on informatics.

https://www.longtermplan.nhs.uk/online-version/

http://www.legislation.gov.uk/uksi/2012/1631/schedule/1/made

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5.3 Criteria for merger

36. In accordance with the legal requirements and the NHS Long Term Plan, NHS England will consider the following criteria in deciding whether to approve a proposed merger:

i. Alignment with (or within) the local STP/ICS: to provide the most logical footprint for local implementation of the NHS Long Term Plan, and to provide strategic, integrated commissioning to support population health. The merger application should briefly set out how the proposed new CCG will work with all other local STP/ICS partner organisations (including any other CCGs, in line with the legal requirements) and (where relevant) other partner organisations (including other CCGs/providers) outside the existing STP/ICS with which it has significant working relationships. Any CCG merger proposal which crosses existing STP/ICS boundaries may prompt consideration of whether the existing STP/ICS boundaries are themselves appropriate or need to be re-drawn.

ii. Coterminosity with local authorities: there is a presumption in favour of the proposed new CCG being coterminous with one or more upper-tier county council or unitary local authority. The existing CCGs must demonstrate how the merger would be in the best interests of the population which the new CCG would cover. This is particularly important in any case where the boundary of the proposed new CCG is not coterminous with local authority boundaries. In all cases, in line with the legal requirements, the existing CCGs must demonstrate in their application that they have effectively consulted with the relevant local authority(ies) regarding the proposed merger, record what the local authority(ies)’ views are, and what the CCGs’ observations on those views are. They should also show how they have/will put in place suitable arrangements with local authorities to support integration at ‘place’ level (population of between 250,000 and 500,000).

iii. Strategic, integrated commissioning capacity and capability: in line with the legal requirements, the existing CCGs must demonstrate that they have/will develop the leadership, capacity and capability for strategic, integrated commissioning for their population. This will include population health management, new financial and contractual approaches that encourage integration, and developing place-based partnerships. In accordance with the legal requirements, the application must demonstrate how any commissioning support services to be procured will be of an appropriate nature and quality.

iv. Clinical leadership: in line with the legal requirements, the existing CCGs must demonstrate how the proposed new CCG will be a clinically-led organisation, and how members of the new CCG will participate in its decision-making.

v. Financial management: in accordance with the legal requirements, the existing CCGs must show how the new CCG will have financial arrangements and controls for proper stewardship and accountability for public funds.

vi. Joint working: ideally, a merger should build on collaborative working between the existing CCGs and represent a logical next step from current arrangements. The merger application should show progress on joint working to date, and must show how the existing CCGs intend to resource and manage the merger process itself.

vii. Ability to engage with local communities: assurance is required that the move to a larger geographical footprint will not be at the expense of the proposed new CCG’s ability to engage with - and consider the needs of - local communities.

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viii. Cost savings: where possible, the existing CCGs should show how collaboration and joint working to date has contributed to cost savings; they must also show any further cost savings projected to result from the merger, and when, and how cash released will be re-invested.

ix. CCG Governing Body approval: the merger application must show evidence of approval for the merger by the Governing Body of each of the existing CCG governing bodies.

x. GP members and local Healthwatch consultation: evidence is required that each of the existing CCGs have engaged with, and seriously considered the views of, their GP member practices, and local Healthwatch, in relation to the merger. The merger application must record the level of support and the prevailing views of each existing CCG’s member practices and local Healthwatch, and the existing CCGs’ observations on those views.

5.4 Pre-application activity and the merger application 37. CCGs contemplating merger should engage at the earliest possible opportunity with the

relevant NHS England regional team, prior to making a formal application. NHS England will work with CCGs to minimise the risk of unnecessary work and to support their engagement with stakeholders and application preparations. The CCGs should make regional teams aware of all existing and planned joint appointments and collaborative working arrangements, e.g. committees in common, which are/will be in place prior to merger.

38. The relevant NHS England regional team should indicate promptly to the existing CCGs

whether it is supportive in principle of the proposal to merge. If the regional team is supportive, the CCGs are strongly encouraged to start early engagement on the merger with their members, staff, local communities (including through local Healthwatch) and their local authority and provider organisation partners.

39. CCG merger applications may be made – and considered by NHS England - at any time

of the year. However, mergers may only take effect from the beginning of a new financial year (1 April). If a proposal to merge is supported by the relevant regional team, a formal, written application should be made jointly by the existing CCGs to the relevant Regional Director. Formal applications should be made to the Regional Director by 30 September for the merger to take place on 1 April the following year. As an exception, late applications by 31 October 2019 will be considered on a case by case basis where they support implementation of the Long Term Plan. CCGs are encouraged to make an early application to give them sufficient time post-conditional authorisation to work with NHS England and other partner organisations (notably NHS Shared Business Services (SBS) and NHS Digital) on the detailed implementation and preparatory arrangements.

40. The Regional Director will acknowledge receipt of the merger application in writing within

two weeks of receipt.

41. Any application received by the Regional Director after 31 October will be considered for merger the April after next. In this case, following conditional authorisation of the merger by NHS England, the existing CCGs will default to operating (as far as possible) as a single organisation and will have longer to prepare for their formal merger.

42. The formal merger application must be signed off by the Accountable Officer for each of the existing CCGs and include a statement of confirmation that the decision to apply for merger has been taken in accordance with each of the existing CCGs’ governance

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arrangements. More details about the application requirements are shown at Annex C. The application must set out how the proposed merger will meet the criteria for merger and include selected supporting evidence (where appropriate). As part of this, there should be information about the benefits of joint working between the CCGs to date (quantified, where possible, e.g. financial savings) and an outline benefits realisation plan for the pre-merger period and post-merger. This should show the anticipated benefits of the merger, when they are expected to be realised and how they are to be measured/evaluated.

43. Leaders of the existing CCGs will be invited to present their pre-submitted merger application and supporting evidence for scrutiny by a regional panel, which may include, at the discretion of the Regional Director and, only if there is no conflict of interest, leaders from the local STP(s)/ICS(s), to offer their observations. This is an opportunity for ‘check and challenge’ of written information submitted. If the regional panel and Regional Director make a positive assessment of the merger application following the panel presentation, the decision to approve the application, including determining any specified actions and conditions which must be completed prior to the merger, will be made in accordance with NHS England’s Scheme of Delegation. The decision on conditional authorisation will be reported to the next meeting of the Board or at an earlier opportunity.

44. The existing CCGs will be informed of the decision taken in writing by the Regional

Director. The decision is final and there is no right of appeal.

6 Procedure to dissolve a CCG

6.1 Background

45. Section 14H of the Act, provides that a CCG may apply to NHS England for the group to be dissolved and for its members to join other CCGs.

46. Key factors set out in the Regulations that NHS England must consider in relation

to an application for dissolution are: a. the impact on the local population served by the dissolving CCG of

proceeding with a dissolution; b. the financial implications of dissolution to both the CCG in question and

other affected CCGs;

c. the impact on NHS England’s functions; and

d. the stakeholder engagement the CCG has undertaken and how the CCG has taken the views of stakeholders into account.

6.2 Application process to be adopted

47. NHS England will consider applications for CCG dissolutions at any time in the year. This is because it needs to ensure that the entire population is always covered by a functioning CCG. Submissions should be made to the relevant regional team.

48. The application should come from the CCG wishing to dissolve. The application

should already have been discussed and agreed with CCG member practices and stakeholders, including those neighbouring CCGs which will be affected by the dissolution, should have already been consulted at the point of submission of the application.

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49. Applications made under section 14H of the Act must be accompanied by the following:

a. assurance that all member practices of the CCG have plans in place to join other CCGs;

b. confirmation that those other CCGs have been consulted and are content with the proposals for new members; and

c. assurance that other stakeholders have been consulted.

50. CCGs receiving new practices as a result of a CCG dissolution should apply to vary their constitutions in tandem with the application for dissolution and to an agreed common timescale.

6.3 Consideration by NHS England of the proposed dissolution

51. Regulation 9 applies to applications to dissolve a CCG. Schedule 3 to the

Regulations sets out the factors to be taken into account. NHS England may also consider any other information which it deems relevant. The factors that must be considered are as follows:

a. the likely impact of the dissolution on population and patients of the CCG;

b. the likely impact of the dissolution on financial allocations;

c. the likely impact of the dissolution on NHS England’s functions;

d. the extent to which the CCG to be dissolved has sought the views of the following, what those views are, and how the CCG has taken them into account:

o unitary local authorities and upper tier county councils (within the

meaning of paragraph 1 (2) of Schedule 1) whose area coincides with, or includes the whole or any part of, the area specified in the CCG’s constitution;

o any other CCG which in the CCG’s view would be affected by the dissolution; or

o any other person or body which in the CCG’s view might be affected by the dissolution; and

e. the extent to which the CCG to be dissolved has sought the views of individuals to whom any relevant health services are being or may be provided, what those views are, and how the CCG has taken them into account.

52. Additionally, on receipt of an application for dissolution NHS England can consider the requirement to apply the failure regime under section 14Z21, and potential need for directions to support the carrying out of the CCG’s functions in the period until dissolution takes effect.

53. If only some member practices have agreed plans to move to other CCGs, NHS

England will consider whether the residual practices can form a viable CCG. If necessary, NHS England will consider the use of its powers under 14F to vary the membership of a CCG. NHS England will consider this on a case by case basis and in discussion with the CCG.

54. NHS England may refuse an application for dissolution if it is not satisfied that the

alternative CCGs would meet the same threshold as required for initial authorisation.

55. NHS England will also assess, where relevant, whether the CCG(s) have ensured that appropriate plans are in place to maintain good information governance

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through the transition, in consultation with local IG Lead(s) – in particular for: a. appropriate transfer or disposal of information assets, including manual

records and electronic equipment;

b. physical audit of premises prior to release;

c. review of Data Protection Notification(s); and

d. revision to Fair Processing Information.

56. NHS England will acknowledge all applications for dissolution within two weeks of receipt.

57. If NHS England thinks that its statutory duties in relation to CCGs make it

preferable for it to do so, it may: a. where granting the application would have a significant impact on

allotments to the CCG in question or other CCGs, defer determination of the application until the end of the financial year in which it was received and the date six months after it was received, whichever is the later; or

b. defer determination until it has received all related applications for establishment or variation from other CCGs.

58. In the event of dissolution, the assets and liabilities of the CCG will transfer to the organisation(s) to which the practices within that CCG become members. The dissolving CCG will need to confirm the split of assets and liabilities across practice populations. Where there is a dispute regarding the transfer of assets or liabilities, NHS England will determine the proportions to be allocated to the receiving CCGs. NHS England may make a property and/or staff transfer scheme as appropriate under section 14I of the NHS Act 2006. In the event of CCG functions being taken over by NHS England (as a result of its intervention procedures), any assets and liabilities will be transferred to NHS England proportionate to the functions being discharged.

59. There is no right of appeal to NHS England’s decision.

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Annex 1: Checklist for constitution changes

For completion by CCGs – and submission to their regional teams:

CCG name

Reason for variation

Have the requested variations been made in tracked change(s) for ease of review by regional team?

Have member practices agreed to the proposed change(s)?

Have the relevant stakeholders been consulted (if required)?

Has the Chair or Accountable Officer confirmed that the revised constitution meets the requirements of the Act on behalf of the CCG?

Have you considered legal advice where necessary?

Have you completed an impact assessment of the changes to be considered by NHS England?

Have you included practice codes for any proposed practice moves if applicable?

Have you included LSOA codes for any proposed boundary changes if applicable?

Have you included a map as part of your submission?

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Annex 2: Legal requirements of a CCG constitution

The full requirements of what a CCG must and may include in its constitution are provided in Schedule 1A Part 1of the 2006 Act (as amended.) The essential legal requirements are listed below.

Name

Members

Area

Arrangements made for discharge of functions including terms and conditions of employees

Procedures for making decisions

How to achieve transparency about decision making

Arrangements to be made for discharging its functions under Section 140 of the Act, i.e., the requirement upon the CCG to maintain registers of interest, publish those registers, ensure anyone affected declares conflicts or potential conflicts of interest and have regard to any guidance issued by NHS England on conflicts of interest.

Effective participation by all members

How the governing body will operate

Arrangements for the appointment of the audit and remuneration committees

Governing body decision making processes

Provisions for public meetings

http://www.legislation.gov.uk/ukpga/2012/7/schedule/2/enacted

https://www.england.nhs.uk/commissioning/pc-co-comms/coi/

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Annex 3: Merger application requirements

The merger application should be clear and concise.

The application should include the following:

1. Summary case for change document (no longer than 15 pages), to include: - signatures of the existing CCG Accountable Officer(s) and a declaration that the

decision to apply for merger is made in accordance with each of the existing CCGs’ governance arrangements

- the proposed new CCG name (to comply with the CCG Regulations 2012 (3) to (6)) - map(s) and population details; reference to current health outcomes and health

inequalities - reference to the PSED (Public Sector Equality Duty) impact assessment for the

proposed new CCG - the reasons for the application (to comply with the CCG Regulations 2012 10 (4)) and

an outline description of benefits of merger, including the impact on the registered and resident population of the new CCG, the impact on STP/ICS partners and any other significant partner organisations

- summary of joint working to date, including joint appointments, committees in common, lead commissioner arrangements, etc.

- confirmation of Governing Body support for the merger from each of the existing CCGs - reference to the merger communications and engagement plan, including confirmation

of engagement of the relevant local authorities, the membership of the existing CCGs and local Healthwatch and consideration of their feedback

- financial position (current and high-level forecast) - reference to any intervention action for any of the existing CCGs (current or past) –

legal directions/special measures - reference to current status regarding delegated authority for primary medical care

services - desirable – as an appendix: joint letter of support from STP leaders for the

merger.

2. Completed application template (Excel spreadsheet – template to be supplied by NHS England – setting out the merger criteria) – showing how the application meets the criteria for merger (including legal requirements), and signposting to the supporting evidence.

3. Outline benefits realisation plan – what benefits are expected to be realised from the

merger? To include high level view on impacts on population health and financial savings. Identify baseline measures to enable evaluation of benefits post-merger.

4. Impact assessment of the proposed CCG’s Public Sector Equality Duty (PSED) including

the protected characteristics (Authorisation criteria, Equality Act). For the proposed new CCG:

5. High level HR/OD strategy – showing how key capacity and capability requirements will be met to provide an effective integrated strategic commissioning function, and locality place-based commissioning.

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6. Procurement plan for key support services.

7. Clinical commissioning strategy/population health management plan.

8. Communications and engagement strategy/plan.

9. Financial strategy/plan.

For the merger process (prior to the new CCG being established on 1 April):

10. High level merger programme plan, to include:

• resources (financial and staff) (to be) committed by the existing CCGs to the merger

• governance and reporting arrangements for the merger project – SRO, PMO, merger oversight group; external reporting to NHS England

• key workstreams: HR and OD (including recruitment to Governing Body and other key roles), governance for the new organisation (including plan for production of a new Constitution and Standing Financial Instructions (SFIs), finance, informatics, information governance, communications and engagement*, estates and property (asset management)

• key milestones

• key dependencies

• risks and issues.

11. Merger communications and engagement plan*, to include:

• stakeholder mapping (with specific reference to CCG member practices, STP leaders and local Healthwatch)

• summary of key activity to date, including any media interest, feedback received, and response to date

• summary of planned future activity. NHS England may also request additional evidence, so this checklist should be treated as an indicative list only. It is also recognised that similar documents may have different titles/descriptions, so flexibility is allowed for this. In addition, there is flexibility for CCGs to submit additional evidence in support of their application, but this should be kept to a minimum – and only included where it adds significant value to the case for merger.


Shropshire CCG Governing Body meeting: 08.05.19


System Operating Plan and the Shropshire CCG Operating Plan 2019-20 – update


Gail Fortes Mayer


Gail Fortes Mayer

Presenters:

David Stout – Accountable Officer Gail Fortes Mayer – Director of Contracting & Planning


To present the draft System Operational Plan for the Shropshire and Telford & Wrekin STP and the final Shropshire CCG Operating Plan for 2019-20

To outline the key areas of the plan and their alignment to key policy requirements e.g. NHS Long Term Plan, NHS Planning, Contracting and Payment by Results guidance for 2019-20.

To note that the CCGs Operating Plan is a key component of the Shropshire and Telford & Wrekin System Operational Plan.

Summary and key points to note: The STP Operational Plan (Enc. 1) sets out how the STP has worked collaboratively to develop a single working document. This draft system wide plan recognises the need for transformation across all the STP partners to make the best use of the collective resource across Shropshire County. The Shropshire CCGs (SCCG) Operating Plan for 2019-20 (Enc. 2) is a key component part of the wider health and social care economy system plan. The document sets out SCCG work programme relative to the STPs draft Operational Plan; taking account of key national documents for example the NHS Operating Guidance 2019-20. Both plans are integral to the delivery of the NHS Long Term Plan. 1, The STP system Operational Plan sets out the context of the system and outlines the ambitions to address them as a health and care system.

System Challenges and Integrated Care System (ICS) Development – this section outlines geography and demographics as key challenges the system faces. It identifies the cultural shift required to move away from the inherent medical model to one of prevention, self-help and prevention. It continues to note that the system needs to reverse its operational, financial, workforce, quality and reconfiguration challenges, to be in a position to develop into and Integrated Care System (ICS) by 2021-22.

System Structure Governance and Performance – the section sets out a draft of the refreshed governance structure, including a set of consistent governance principles throughout the STP work streams. The expectation is that the use of system level data with be drive forward system change, together with routinely generated performance data. The Managing Collective Financial Resources (MCFR) framework has been developed to support the effective management of the systems collective resources. This MCFR framework covers six key activities considered critical to collectively managing financial resources:

o A well-constructed operating plan which aligns activity, finance and workforce; o Shared approach to investment; o System level financial governance arrangements; o Analytic and data to monitor progress; o Agreement on efficiencies to secure in-year and longer term financial sustainability; and o Aligned incentives and payment mechanisms.

System Ambition and Priorities. This section outlines the ambitions for joined up health and care for people within the Shropshire and Telford & Wrekin (STW) STP. The ambition being to work with a range providers to deliver services at a place level, designed on the needs of the local population through: engagement with staff and populations to effectively utilise health and social care resources. Quality is a key priority with a System Quality Focus set out in the document.

System Delivery Programmes. There are nine system wide delivery programmes; each with key priorities and deliverables, set out in the system operational plan, including:

o Population health and prevention; o Primary Care; o Out of hospital integrated care (including personalised health budgets and social prescribing0; o Musculoskeletal (MSK) Transformation Programme; o Local Maternity Services; o Accident & Emergency (A&E) performance trajectory – top three priorities for 2019-20.; o Urgent and Emergency care; o Cancer and referral to treatment; and o End of Life care.

System Enablement Programmes – there are four cross cutting enabling programmes identified that underpin the STP in its development to addressing system level challenges and delivering ambitions of the delivery programmes. Each of the enabler programmes has an executive senior leader representative on the System Leaders Group (SLG). The four cross cutting programmes include:

o System strategic approach to workforce – underwritten by the STP People Strategy; o System strategic Estates – “people and place, but not building focussed”; o System Digital Enablement – underwritten by the Local Digital Roadmap (LDR); o System Communication & Engagement.

System Activity and Capacity Planning – the STP system Operational Plan notes that the systems activity and capacity planning is ever evolving, and will be so in a transforming system. The section outlines the systems approach to capacity planning to recover and/ or deliver constitution requirements. Evolution of the systems transformation of services will require updates to the activity and capacity assumptions.

System Finances, planned recovery and efficiencies (and financial appendices) – this section outlines the system wide savings required for the STW STP to break even as £51.6m The systems transformational change programme identifies pipelines opportunities of £53m over the coming four years. There is an STP wide commitment to accelerating work across programme to deliver saving sooner, however it is noted that the full gap is unlikely to be realised in 2019-20 due to the

transformational nature of the work required. 2. The Shropshire CCG Operating Plan for 2019 -20 is a component part of the STP System Operational Plan. This plan covers the following work areas/ programme for 2019-20.

Activity Plans and Growth Assumptions – noting the requirements of the national planning guidance, activity plans have been developed by taking account of service developments and transformational aspirations to improve efficiency. The growth assumptions presented are net of QIPP schemes.

Finance and Sustainability – noting the inherent Legal Directions and Special Measures; SCCG continues to face significant financial challenges. The Operating Plan briefly describes the processes to balance transformational change with delivery expectations in a financially challenged economy.

Planned Care – working closely with Telford & Wrekin CCG (T&W CCG), SCCG intentions are to develop streamlined and consistent care pathways across the county, but not exclusively, in the following areas of care:

o Outpatient services, Cancer treatment, Musculoskeletal (MSK) services; neurology services, local maternity and services for women and children.

Mental Health (MH) & Learning Disabilities (LD). The golden thread for SCCG is to have MH & LD woven into all care delivery, from early targeted intervention to enhanced recovery closer to home. This includes ensuring the physical health needs of people with long term mental health or learning disabilities are managed appropriately.

Urgent and Emergency (U&E) Care. Shropshire CCG (SCCG) has two key strands of work for 2019-20 in the area of U&E Care development:

o the Shropshire Care Closer to Home programme and o Improving existing Urgent Care Services.

Cancer Services – the strategic aims across the STP partners is for fewer people to be diagnosed with preventable cancers; improved mortality rates for cancer in Shropshire and at whatever point in screening or treatment, services are accessible, timely and sustainable for Shropshire people.

Primary Care – the key areas of work for primary care in 2019-20 include: o Primary Care Network (PCN) development; o Primary Care Access; o Workload and workforce; o Primary Care digital and estates; o Primary Care Quality; o Prevention and tackling Health Inequalities, and o Delegated Commissioning.

Medicines Management – the work plan for Medicines Management focusses on QIPP Prescribing schemes delivery, not simply the quick wins, but looking to the future to ensure the most economical approach to safe treatment. Medicines management is a key enabler to the delivery of the longer term objectives of the CCGs/ STP.

Quality, Personal Health Budgets and Patient Engagement – quality of services the CCG commissions is a key consideration to ensure patient safety, effectiveness of care and service/ user experience, in everything the CCG does. Personal Health Budget will be a focus area for the CCG in 2019-20 to deliver the requirements of the NHS Model of Personalised Care. Patient engagement – the plan sets out the desire to build on the successful approach taken in the Future Fit consultations. The objective for 2019-20 will be to ensure cohesion of patient engagement with the commissioning programmes of work.

Digital Technology – the plan recognises the value of digital as a key enabler to the delivery of CCG, STP and NHS plans. As a stakeholder of the STP SCCG will develop a work plan to support delivery of the Local Digital Roadmap (LDR). Developing primary care technology is a key area of work for 2019-20, which will enable longer term developments across the economy, for example record sharing to facilitate Care Closer to Home.

Corporate Governance, Organisational Development and Risks - are noted in the final section of the Operational Plan. Key themes are addressed throughout the document, which are underwritten within directorate work programmes and will be monitored through the Governing Body.

Actions required by Governing Body:

Note the content of the draft System Operational Plan for the Shropshire and Telford & Wrekin STP the and the Shropshire CCGs Operational Plan for 2019-20.

Note the Shropshire CCG Operational Plan for 2019-20 is an integral component of the system level Operational Plan.



NHS funding allocation for 2019-20.

2 Health inequalities Yes/No If yes, please provide details of the effect upon health inequalities



Clinical engagement has taken place during the development of this document although this has been at a very high-level. Plans set out here outline intentions towards ensuring a significant degree of clinical input is achieved.



Shropshire CCG Operational Plan Narrative 2019/20

1

Shropshire Clinical Commissioning Group (CCG)

Operational Plan 2019/20


2

1 Introduction

Shropshire CCG has a population with a marked older age structure than the country as a

whole and consequently experiences a disproportionate impact from the problems

associated with an ageing population. This manifests in high proportion of long term

conditions and the increasingly likelihood of being a contributory factor to problems evident

in the local urgent care system.

With the exception of performance and delivery issues in urgent and emergency care

Shropshire CCG compares well on other health and care performance indicators; with

performance being ahead of the national average generally.

However Shropshire CCG continues to face significant financial challenges as part of its

financial recovery as a member of an overall health economy that has substantial and

longstanding financial hurdles that need to be addressed.

The decision to support the preferred option for the redesign of acute services across

Shropshire, Telford & Wrekin – Future Fit will allow £312m investment to be confirmed into

the health and social care system. This investment provides the wider health and social

care system of Shropshire and Telford & Wrekin the opportunity to re-shape care provision

across the county and beyond.

Future Fit provides an opportunity, over the forthcoming number of years, to:

re-design acute services,

deliver care closer to home,

re-shape community service provision,

raise the level of investment in mental health services and

improve outcomes for patients will present significant opportunity, challenge and

change.

The coming years offer a ‘once in a generation’ opportunity for the local health economy to

develop a modern, targeted and responsive service. The CCG, and its partners, will construct

and deliver the plans to turn this into reality.

Enabling the future is key to its delivery and this Operating Plan for Shropshire CCGs sets out

the organisations objectives, within NHS planning guidance for 2019-20, with the longer

term deliverables clearly in focus.


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The Shropshire CCG Operating Plan for 2019 -20 covers the following work areas/ programme for 2019-20.

Activity Plans and Growth Assumptions – noting the requirements of the national planning guidance, activity plans have been developed by taking account of service developments and transformational aspirations to improve efficiency. The growth assumptions presented are net of QIPP schemes.

Finance and Sustainability – noting the inherent Legal Directions and Special Measures; SCCG continues to face significant financial challenges. The Operating Plan briefly describes the processes to balance transformational change with delivery expectations in a financially challenged economy.

Planned Care – working closely with Telford & Wrekin CCG (T&W CCG), SCCG intentions are to develop streamlined and consistent care pathways across the county, but not exclusively, in the following areas of care:

o Outpatient services, Cancer treatment, Musculoskeletal (MSK) services; neurology services, local maternity and services for women and children.

Mental Health (MH) & Learning Disabilities (LD). The golden thread for SCCG is to have MH & LD woven into all care delivery, from early targeted intervention to enhanced recovery closer to home. This includes ensuring the physical health needs of people with long term mental health or learning disabilities are managed appropriately.

Urgent and Emergency (U&E) Care. Shropshire CCG (SCCG) has two key strands of work for 2019-20 in the area of U&E Care development:

o the Shropshire Care Closer to Home programme and o Improving existing Urgent Care Services.

Cancer Services – the strategic aims across the STP partners is for fewer people to be diagnosed with preventable cancers; improved mortality rates for cancer in Shropshire and at whatever point in screening or treatment, services are accessible, timely and sustainable for Shropshire people.

Primary Care – the key areas of work for primary care in 2019-20 include: o Primary Care Network (PCN) development; o Primary Care Access; o Workload and workforce; o Primary Care digital and estates; o Primary Care Quality; o Prevention and tackling Health Inequalities, and o Delegated Commissioning.

Medicines Management – the work plan for Medicines Management focusses on QIPP Prescribing schemes delivery, not simply the quick wins, but looking to the future to ensure the most economical approach to safe treatment. Medicines management is a key enabler to the delivery of the longer term objectives of the CCGs/ STP.

Quality, Personal Health Budgets and Patient Engagement – quality of services the CCG commissions is a key consideration to ensure patient safety, effectiveness of care and


4

service/ user experience, in everything the CCG does. Personal Health Budget will be a focus area for the CCG in 2019-20 to deliver the requirements of the NHS Model of Personalised Care. Patient engagement – the plan sets out the desire to build on the successful approach taken in the Future Fit consultations. The objective for 2019-20 will be to ensure cohesion of patient engagement with the commissioning programmes of work.

Digital Technology – the plan recognises the value of digital as a key enabler to the delivery of CCG, STP and NHS plans. As a stakeholder of the STP SCCG will develop a work plan to support delivery of the Local Digital Roadmap (LDR). Developing primary care technology is a key area of work for 2019-20, which will enable longer term developments across the economy, for example record sharing to facilitate Care Closer to Home.

Corporate Governance, Organisational Development and Risks - are noted in the final section of the Operational Plan. Key themes are addressed throughout the document, which are underwritten within directorate work programmes and will be monitored through the Governing Body


5

2 Activity Plans and Growth Assumptions

The CCG has analysed trends over the last three years to develop activity plans and growth

assumptions. Further adjustments have then been made to reflect non-recurring/ one-off

factors e.g. clearing Referral To Treatment (RTT) backlogs and the impact of commissioning

intentions.

Application of the NHS Operating Guidance 2019-20 and other local adjustments and

account of local service developments and transformational actions to improve efficiency,

result in a set of planned activity growth assumptions for Secondary care, Mental Health

Services and Prescribing as have resulted in the growth expectations set out below

The planning assumptions therefore recognise a position of relative stability in terms of GP

referrals and outpatient activity, alongside sizeable increases in the volume of A&E

attendances and emergency admissions. Elective daycases show a steady increase whilst the

converse is observed for elective inpatient work, resulting in a modest increase.

The CCG has recognised the need for increased investment in MH Services and particularly

those relating to IAPT.

Growth Expectation for

2019/20

Referrals 0.60%

Outpatients 1.02%

Electives 3.40%

Emergencies 1.60%

A&E 4.10%

Prescribing 3%

Mental Health

To meet the investment

standard

after

impact of

QIPP


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3 Finance and Sustainability

Introduction Shropshire CGG enters 2019/20, the period covered by the NHS Long Term Plan, under both Special Measures and Legal Direction. The CCG has faced, and continues to face, significant financial challenge from which it needs to recover and return to a sustainable finance position. This is at the same time as significant change nationally across the NHS and substantial transformation across the Shropshire community over the coming years. Financial recovery As a commissioner within the Shropshire health and social care system, the CCG faces major financial challenge. Like other organisations within the Shropshire health economy, the CCG continues to spend in excess of its funding allocation and expects to do so for the immediate future, as it works through its Financial Recovery Plan. The CCG has been implementing a Financial Recovery Plan to date and is currently re-casting its plan in-light of current circumstances. This is being done alongside re-alignment of the commissioning and contracting arrangements with providers, in conjunction with partner CCGs and other commissioners. SCCG is tackling change and transformation in line with the NHS Long Term Plan and other substantial projects, including Future Fit and Shropshire Care Closer to Home, which together fundamentally re-shape delivery of healthcare and prevention in Shropshire; rebasing the costs associated with delivery whilst, continuing to commission high quality services. Shropshire CCG is continuously looking for opportunities to improve productivity internally and the wider system; both through major transformation projects and more generally in its wider functions with our partners, where appropriate.


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4 Planned Care

Introduction

In 2019-20 Shropshire CCGs has outlined a number of aims it wants to pursue in the area of

planned (elective) care.

These include:

streamlining care;

ensuring robust pathways are in place;

commissioning capacity based on realistic and planned demand; and

improve patient’s experience of appointments and treatment.

In 2019 -20 Shropshire and Telford & Wrekin CCGs will be working closely to develop

streamlined pathways for planned care across the whole health economy in a number of

areas including:

I. Outpatients activity

II. Cancer treatment

III. Musculoskeletal (MSK) services

IV. Neurology services

V. Local maternity services

I. Referral to Treatment / Outpatients

The NHS Constitution promises patients the right to start consultant led treatment within a

maximum of 18 weeks from referral; to not wait more than 6 weeks for diagnostic tests and

not wait more than 52 weeks for treatment.

This commitment is strengthen in the NHS Long Term Plan and to action this Shropshire

CCG will:

Monitor the acute trusts waiting list to ensure that at the end of March 2020, the

waiting list size, does not exceed that of the waiting list at the end of March 2018;

Work with its providers to develop a process for identifying patients exceeding 6

months on the waiting list and offering them the opportunity to move to an

alternative provider;

Refine the existing process for identifying patients approaching 40 weeks on a

provider waiting list to ensure no patient exceeds 52 weeks by April 2020.

As can be seen from the figures below, Shropshire CCG has planned, in its planning

assumptions to deliver RTT and planned diagnostics trajectories and for no patients to be

waiting over 52 weeks for treatment


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The CCGs plan to undertake a programme of work in relation to outpatients redesign to

drive efficiencies across outpatient provision by undertaking the following actions:

Identifying areas where non face to face appointments can be implemented;

Exploring areas where patient led follow ups can be implemented;

Identifying technological opportunities in relation to outpatient appointments.

II. Cancer Treatment.

The strategic ambition for Shropshire is for fewer people to be diagnosed with preventable cancers; improve mortality rates for cancer sufferers and improve patient experience. This will be through whole system working with colleagues across the health and social care setting.

The work on cancer for 2019-20 across the STP health and social care economy is focussing on recovery of the cancer performance targets for the diagnosis and treatment targets for cancer. Shropshire and Telford & Wrekin CCGs are focussed on addressing some of the fragile cancer

services which have contributed to the fall in performance delivery. Improvement plans agreed with NHSI are in place at SaTH for all cancer services, and with the exception of Urological cancer, there is confidence that performance standards in terms of waiting time can be achieved and maintained through 2019/20. Like other parts of the country, problems with capacity relating to Urological cancer are expected to continue through 2019/20. Potential improvements for this area including more joint working, technological developments and sharing of workload will be explored.

This work is also supporting the transformational work at a West Midlands Cancer Alliance

(WMCA) level, which should support the delivery of sustainable services. There are four regional

pathways commissioners will be focussing on: Upper Gastro Intestinal, Lung, Breast and

Prostrate. The latter two being fragile services in Shropshire county.

.

April May June July August SeptemberOctober NovemberDecemberJanuary February March

52 week

waiters

plan

0 0 0 0 0 0 0 0 0 0 0 0


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III. Musculoskeletal (MSK) Service Model Redesign

In April 2018 Shropshire CCG implemented a new service delivering a community based

triage, assessment, diagnosis and treatment service for MSK conditions.

In 2019-20 this work with continue in relation to MSK services during 2019/20 including:

Reviewing MSK services within the community and within secondary care

providers;

Evaluating the First Contact Practitioner (FCP) pilot with a view to embedding FCP

within the new service model

Developing a single service model for the whole MSK pathway which

incorporates First Contact Practitioner, community services and surgical

interventions.

It is expected that this approach should streamline patient journeys and reduce unnecessary

surgery.

IV. Neurology Service Model Redesign

The neurology service delivered at Shrewsbury & Telford Hospitals (SaTH) has been

challenged for many years, primarily due to the workforce limitations. A decision to close

the service to new referrals was made in March 2017 and the two CCGs have struggled to

secure a sustainable service across Shropshire to date.

Therefore, the two CCGs are committed to undertake the following work during 2019/20 to

develop sustainable neurology services across the county:

Develop a new model of service delivery for neurology increasing community based

support;

Increase access to nurse led support for people with neurological conditions;

Commission the new model of service delivery from a new provider, likely to be in a

networked model.

V. Women’s and Children’s Care

There is a large Women’s and Children’s agenda for Shropshire CCG and across the wider

county. Shropshire CCG has identified the following areas of focus 2019/20.

Special Educational Needs (SEND) - Children

Development and implementation of local SEND partnership arrangements which

will include Education Health and Care Plan (ECH); Children & Young Peoples (CYP)

participation (as well as carers and parent, and Joint Commissioning arrangements

including an Outcomes Based Framework.


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Complex Care Needs

This will include the audit of current packages of care; the development of pathways

and effective signposting, review of existing financial allocation / framework, and the

development of robust governance and accountability arrangements

Service Users Participation

Encourage and facilitate the participation of children and young people in the

development of services.

Children’s Services in the Community – there are a number of service area that the

CCG will address in 2019-20, including: service specifications for community therapy

- alignment with T&W CCG; Constipation advice pathway to be revised; Severndale

school – pathway development and clarification regarding Children’s Community

Nurse (CCN) team responsibilities; final recommendations regarding psychology

service review (in conjunction with Telford and Wrekin CCG). Audiology Services -

development of a comprehensive all age pathway.

Looked After Children (LAC) – service focus areas in 2019-20 will include; a review

and revision of the Looked After Children (LAC) service specification, the

implementation of LAC health assessments and LAC passports; audit of health

assessments. There is also to be a review of the financial allocation for joint

commissioning arrangements based on health outcomes.

Acute Paediatric Services – the paediatric acute work stream for 2019 – 20 will focus on:

Review current activity and explore options to reduce zero length of stays for

children.

Those children who are admitted, review the discharge arrangement from HDU

Review of the Paediatric Diabetes best practice tariff;

Review activity and pathways with an aim of reduce A&E attendance and bed

days (Big 6 – children’s health conditions)

Review the Paediatric Asthma pathway.

Delivering Better Births – the CCG will focus its work on delivery of the national policy

objectives in the context of reshaping local midwifery led services.

Improving CAMHS Services - the CCGs will continue to drive the improvement plan for

CAMHS services across the county.


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5 Mental Health & Learning Disabilities

Introduction

The NHS ‘Long Term Plan’ describes how prevention, reducing stigma and early intervention are critical to maintain wellbeing. The ambition of Shropshire CCG is to have mental health woven throughout health care delivery – from prevention and early intervention through to work on long term conditions.

It is expected that this approach will address the impact of emotional trauma on individuals, health and care systems need to become more trauma informed, and effectively integrate both mental and physical health care to support people’s recovery and wellbeing.

The aims of Shropshire CCG are to improve the recovery outcomes for people of all ages including; children and adults, with mental health, learning disability and autism. This will be delivered through the following:

Implementing neighbourhood care models of care which includes reviewing and developing stronger place based integrated care models, which are more proactive and recovery based to prevent care needs from escalating and reducing the number of people who need inpatient acute care. Complimented by a move towards new place-based, multidisciplinary model of care, mental and physical health services will be aligned with primary care networks.

Addressing the needs of vulnerable populations such as improving services for people with learning disabilities or autism through the development of a new strategy and clear actions for improvement. This will include planning for an all age intensive support team to work with individuals and families at home, reducing the need for hospital care wherever possible.

Implementing perinatal mental health support for new mums and dads, their babies and families in line with the national programme of new care models.

Improving the crisis response to reduce unplanned admissions to hospital and for people in distress by:

enhancing the single point of access to services, 24/7,

strengthen our holistic out of hours crisis offer, and explore with police and ambulance services the benefits of ‘street triage’ as a potential service development.

explore how the innovative dementia crisis service can be integral to the Care Closer to Home programme.

explore the use of digital solutions to help people requiring urgent care.

Continuing to build on current Early Intervention in Psychosis and Liaison Psychiatry services.


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Implementing the Children’s and Young People’s Local Transformation Plan (CYP-LTP) to:

deliver new care pathways for children and adolescents with mental health needs, reducing the need for hospital and residential care

deliver routine recording and reporting of outcome measures.

develop trauma informed care pathways that truly reflect and recognise the psychological and social injuries people experience from disrupted attachments, childhood adversity and the harms caused by current service models (i.e. Looked After Children).

Improve primary care mental health by expanding access to IAPT services for adults and older adults with common mental health problems, with a focus on those with long-term conditions.

Reducing suicide by implementing the suicide prevention strategy and working across all statutory and voluntary community sectors to implement changes that will reduce of suicide rate to the CCGs ambition of zero suicides.

Investing in the physical health care assessments and interventions for those with serious mental illness. Address the fact that people with serious and long term mental health needs have a life expectancy 20 years less than the average citizen

Continuation of the Individual Placement and Support model to enhance support individuals into work back to work.

Reduce the numbers of people in acute mental health out of area placements. This will be delivered by reducing the number of people placed out of area and consider alternative models such as a high dependency unit for women, or complex needs team.

Review the current mental health rehabilitation and recovery pathway for people requiring longer placements including specialist and community beds.

Further develop localised plans to ensure early diagnosis and help people live well with dementia. This includes achievement of the dementia diagnosis rate and the implementation of effective post diagnosis support pathways across the STP.

Invest in and support workforce to be compassionate, skilled and knowledgeable to continue to deliver our services. Develop plans for the whole mental health workforce, not just NHS but social care and voluntary and care sector. Through new roles make our services the most attractive for new starters, as well as to retain existing valued colleagues.

Optimise better the potential for data and digital technology. This includes website technology for self-care and local service information (such as BeeU children’s services); access to online therapy and materials, use of Apps for assessment and adjunct to therapy and care, and better access to digital tools and patient records for staff, such as in dementia and frailty care for older people.


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6 Urgent and Emergency Care

Introduction Shropshire CCG has embraced many of the components in the NHS Long Tern Plan providing a strong platform on which to expand and reform urgent and emergency care services. Working from this base, these initiatives will be continued into 2019/20. A key priority of focussed development in 2019/20 is the achievement of the A&E 4 hour national standard. Shrewsbury and Telford Hospitals NHS Trust has not achieved the national A&E standard for some time and in the last year performance has deteriorated further. The reasons are multi-factorial but a significant contributory factor is the recruitment and retention challenges of the necessary workforce. The system A&E Delivery Board has developed and is monitoring an action plan for 2019/20 which will enable the acute hospital move toward delivering the national A&E standard.

In support improving A&E performance and having the right services for patient, Shropshire CCG has three main focus area of development for 2019 – 20 in the context of Urgent and Emergency Care, which underpin the future direction of the wider system as we move towards the Future Fit model of health and care deliver. These three strands of work are:

I. Delivery of the A&E performance target An action plan consisting of the following 6 High Impact Change work streams has been developed across the system and monitored at the System wide A&E Delivery Board.:

1. Implement standardised Emergency Department (ED) systems and processes based on

best practice, enhance the workforce and appropriate capacity to improve emergency care

2. Ensure full multi-disciplinary Frailty Front Door Intervention Teams 5 days a week at both acute sites by May 2019, expanded to 7 days a week by October 2019 to ensure that frail patients are identified as soon as they present to the ED or direct to assessment services, and receive specialist, high quality, person-centred care.

3. Enhanced Same Day Emergency Care/Short Stay Assessment models of care Same day emergency care will operate 12 hours a day, 7 days a week with the aim that a third of patients will be managed in this way compared to only a fifth of patients currently.

4. Developing alternatives to ambulance conveyance to hospital 5. Enhance and embed ‘Home First’ services when discharging patients 6. Ensure patients stay in hospital for the minimum time required to manage their

presenting problem Shropshire CCG will also progress a number of initiatives which aim to improve patient outcomes and reduce demand on urgent and emergency care services through primary or secondary prevention. These include the fracture liaison and falls services.

II. Shropshire Care Closer to Home: This is a large-scale programme of transformation which has been underway since November 2017. Redesigning community based services, underpinned by the principles


14

of earlier identification of needs, proactive and preventative interventions, to help keep people as well as possible and at home or in the community for as long as possible. The programme is initially designed around people aged 65 and over with long-term conditions, as the predominant proportion of need in the Shropshire population. The programme will enhance the provision of integrated health and social care to people in their usual place of residence, and prevent the need for a hospital admission for a number of conditions.

Community services will continue to be reviewed to optimise the contribution that integrated multi-disciplinary teams can make to reduce avoidable admissions to hospital and attendances at the Emergency Departments. This informs the developments around risk stratification and integrated Case Management.

The Programme is designed in three phases:

Phase 1 of the programme, or the Frailty Intervention Team, a dedicated multi-disciplinary team based in the acute A&E department who provide a rapid frailty assessment. The aim is to prevent unnecessary admissions, and help navigate them to a more appropriate care setting. This is fully operational at Royal Shrewsbury Hospital, and work is underway to implement the same at Princess Royal Hospital in Telford.

Phase 2 of the programme sees the development of risk stratification used to identify patient needs earlier, establishing dedicated integrated multi-disciplinary health and social care Case Management teams, based in the community and wrapped around primary care, planning and delivering holistic patient-centred care to each individual. Pilot demonstrator sites will be implemented by March 2019, prior to full rollout across the county.

Primary and community care will become the setting of choice for more services. The services people receive will continue to be led by clinicians, but increasing numbers of interventions will take place outside of hospital, with seamless transfer to expert hospital-based secondary care if required.

Phase 3 of the programme is the development of acute and semi-acute services previously ordinarily taken place in a hospital setting, to be provided instead in the home or community. Step Up Community Beds will be developed based on information being received from local population disease prediction and profiling tools. Primary and secondary care clinicians will be enabled to work better together with the patient, using the single patient record.

There will be increased partnership working and integration – e.g. between the Shropshire County Council and the NHS and the NHS and voluntary sector. Commissioners will work collectively with partner organisations to achieve this aim.


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III. Improving existing Urgent Care Services There are a number of focus areas on improving access to urgent care service for the CCG in 2019 -20, these include (but may not be limited to): • High Intensity Service User scheme – expanding on the original 2016 pilot focussing on

frequent A&E attenders, this will be expanded to include frequent ambulance callers • Integrated Urgent Care linking NHS111 and GP Out of Hours with a multi-disciplinary

Clinical Assessment Service was introduced in 2018. Working with the Regional Commissioner this will be expanded to integrate with the Ambulance Service.

• Urgent Treatment Centre – A joint procurement exercise with T&W CCG to deliver an

Urgent Treatment Centre co-located with A&E on both acute sites by April 2020. This will include rapid initial clinical assessment (streaming), pre-bookable appointments from NHS111 and the Ambulance Service and input to the Emergency Care Data Set.

• Delayed Transfers of Care (DToC) – Shropshire CCG and Local Authority intend to

continue to maintain performance below the national 3.5% target and reduce the number of patients with length of stay over 7 days.

• Improving Stroke Services - 2 additional Stroke Consultants will be recruited in 2019/20

to ensure that all patients suffering a stroke are seen and reviewed in line with National Guidance. This will also allow for a 7 day service for people who have had a suspected Transient Ischaemic Attack (TIA). In addition the stroke rehabilitation pathway will be redesigned to allow more people to have rehabilitation in their local community.


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7 Primary Care and Medicines Management

Introduction - Primary Care The main goals for Primary Care in 2019/20 for Shropshire are linked to both the NHS Long

Term Plan and the five year framework for GP contract reform, both published in early

2019.

The work-streams outlined below are detailed in the Shropshire, Telford & Wrekin STP

Primary Care Strategy that was approved by Primary Care Commissioning Committee in

April 2019.

Work-stream Detail Outcomes

Primary Care

Networks

Primary Care Networks (PCNs) centred on

populations of 30,000 – 50,000, led by GP

Practices, are mandated to be set up by 1st

July 2019. The CCG will support practices in

the development of PCNs and will work

with them to deliver the Network Directed

Enhanced Service (DES)

Improved access to Primary Care for

patients through an increase in extended

access appointments.

Increased access to a range of clinicians

through new clinical roles across a

network.

Increased resilience of General Practice

through working at scale.

Workforce The workforce plan is continuing to be

developed and will reflect the introduction

of new clinical roles in the new GP

contract.

The plan will focus on four areas:

1. GP recruitment and retention

2. Practice Nurse development (Including

HCAs & ANPs)

3. The introduction and inclusion of other

clinical roles

4. Cross cutting themes to support the

above areas

An increased and improved workforce,

both numerically and in experience and

skills.

The integration of new roles in Primary

Care, both through schemes linked to PCNs

and through other initiatives

A wide range of clinicians to give patients

further choice and to ensure that they see

the right clinician first time.


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Access The availability of appointments in

Extended Hours (6.30pm-8.00pm Mon –

Friday; Weekends and Bank Holidays) will

double from 30 minutes/1000 population

per week to 60 minutes/1000 population

per week.

The CCG will continue to work with GP

providers to maximise capacity, availability

and utilisation of appointments.

The increase in the availability in extended

hour’s appointments will significantly

benefit patients who work, or those that

rely on family members that work, to

access appointments.

Workload &

Workflow

Work will continue on training (funded

nationally) for Practice administration and

reception staff to support and mitigate the

increasing workload in Primary Care

through the 10 High Impact Changes.

12 practices have recently completed the

Learning in Action programme and 8 are

about to embark on the Productive

General Practice Quick Start programme.

Both of these programmes focus on

Quality Improvement methods that are

easily embedded and shared within and

across practices.

These actions will lead to a workload that is

shared more equitably across the practice

team ensuring that clinicians are free to

focus on the clinical aspects of their role.

Technology &

Digital

The CCG will ensure that the Digital First

vison of the LTP is supported through

primary care. This will include:

Upgrades to practice network

infrastructure and GP IT Hardware

Implementation of the NHS App

Roll out of electronic consultations

software.

This will help to drive improvements in

access to clinical decisions. Patients will

also have easier access to their notes,

appointment booking and repeat

prescription ordering.

Estates A full refresh of our Primary Care estates

strategy is under way and due to be

completed in June 2019.

This will inform our key priorities in both

improvement and replacement of Primary

Care premises to ensure that they are fit to

deliver the clinical priorities and new

models of care.


18


Primary Care

Quality

The CCGs Primary Care and Quality teams

will continue to ensure that high quality

General Practice is central to all plans. This

will be through improved quality visits and

a new quality & performance dashboard.

Consistent, high quality Primary Care

leading to improved patient outcomes.

Prevention

and Health

Inequalities

As part of the PCN development, the CCG

will support networks with the data

required to address key risk factors of

health, including smoking, poor diet, high

blood pressure, obesity and alcohol &

substance misuse

The ability of PCNs to use improved data to

address key risk factors of health should

result in improved health outcomes for

vulnerable patients.

Medicines Management Introduction Medicines management has developed greatly over the last 20 years to become an integral part in

ensuring quality and value for money in primary care and commissioned services. Over the last few

years the medicines management strategy in Shropshire has been successfully focussed on reducing

drug budget spends by optimising cost effective drug choices and active switch programmes.

Remaining opportunities in this area for further financial savings are now limited.

Reducing prescribing spend is a challenge in a time of new innovations and expensive new medicines

There are significant challenges highlighted in horizon scanning for the coming financial year. The

focus for 2019/20 is not on producing further tangible cost savings against budget, rather to

effectively manage growth and optimise use of our financial resources. Over the next five years

medicines management will broaden its focus from predominantly financial outcomes to impacting

on wider health priorities, focussing on reducing health inequalities, hospital admissions, improving

medicines safety, disease prevention and clinical outcomes for patients.

Financial Outcomes. The focus for 2019/20 has been identified using Right Care, EPACT2,

PrescQipp and Keele University prescribing data. There are opportunities for improving both

patients’ clinical outcomes and the cost-effectiveness of prescribing. In 2019/20 we will focus on:

respiratory disease; diabetes; pain management and elderly care. We will continue to make full use

of IT systems such as Scriptswitch to promote cost-effective prescribing and net-formulary as an


19

accessible platform to the new health economy formulary now implemented across Shropshire,

Telford and Wrekin STP.

Shropshire CCG will continue its roll out of the Prescription Ordering Direct Services. The service

currently covers 20 practices and 190K patients and will deliver an estimated £1.3M reduction in

waste from repeat prescribing systems in 2018/19

The CCG will continue to secure best value from medicines and pharmacy by encouraging electronic

prescribing; reducing spends in low value medicines and increasing the uptake of biosimilars in

secondary care as they become available and continuing to encourage GP practices and our

providers to implement the two low value prescribing national policies:

18 items not to be routinely prescribed in primary care.

Conditions for which OTC items should not be routinely prescribed

o Prescribing in OTC items has reduced by almost 10% in 2018/19. We will continue to

promote this with targeted campaigns to both prescribers and the public in 2019/20

Clinical Outcomes: Our target clinical areas for 2019/20: Respiratory Disease, Diabetes, Pain

Management, and Antibiotic Stewardship

Shropshire CCG aims to

Develop and/or review pathways and guidelines to improve prescribing quality and cost-

effectiveness; focussing on reducing unplanned admissions (long-term), improving clinical

outcomes, preventing disease or disease progression and reducing harms from medicines.

Provide education programmes to increase range of skills and competencies in primary care

workforce.

Support the review of clinical pathways in conjunction with our commissioning teams to

identify gaps and opportunities to improve patient care.

Promote a more holistic focus on patient care, rather than considering pharmacological

interventions in isolation.

Care Homes: Polypharmacy and De-prescribing

The CCG has invested in an additional two pharmacists and two pharmacy technicians to improve

medication review of patients residing in care homes in Shropshire. This team aims to:


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Reduce inappropriate poly-pharmacy and support high quality structured medication review

using validated tools such as STOPPSTART, STOPFRAIL in the elderly and to review

overprescribing in people with learning disabilities by increasing awareness of STOMP

principles in primary care.

Improve prescribing in end of life and anticipatory medicines to reduce unnecessary hospital

admissions, increasing clinician’s confidence to appropriately de-prescribe.

Prescribing Safely

Shropshire CCG aims aim to reduce medicines related harms to patients by improving systems in

primary care to identify patients at risk using focussed IT searches and by rolling out the PINCER tool

(a pharmacist-led IT intervention for reducing clinically important errors in general practice

prescribing). Prescribing errors in general practice are an expensive, preventable cause of safety

incidents, illness, hospitalisations and even deaths. Serious errors affect one in 550 prescription

items, while hazardous prescribing in general practice contributes to around 1 in 25 hospital

admissions. PINCER has been shown to reduce error rates by up to 50%.


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8 Quality, Personal Health Budgets and Patient Engagement Introduction Quality in Shropshire CCG is defined as the continuous improvement in effectiveness, experience and safety of health and social care services for the people of Shropshire provided within available resources. Ensuring that CCG strategies prioritise patient centred, evidence based care; the CCG Quality Committee, working in conjunction with managers and clinicians has attempted to achieve a co-ordinated approach to achieving quality across the organisation and with providers. The revised quality strategy therefore has been prepared for 2019-2020 and is aligned to the vision and the agreed strategic objectives of the CCG as described within this operational plan. The CCGs Quality Strategy and objectives for 2019-2020 and the supporting delivery plan set out the key milestones how the CCG will endeavour to ensure that high quality and safe care is always provided and that people experience better care from the services they receive.

The three sub domains of quality are:

1. Patient Safety: The first dimension of quality must be that we do no harm to patients. To achieve this CCG aims to work in partnership and listen to our patients and staff to ensure that commissioned services are provided by the right people with the right skills that are in the right place at the right time Consideration is given to several indicators including:

Serious incidents claims and complaints

National Early Warning Score 2 and Sepsis management

Management of safety alerts

Outcomes of Coroners Inquests

Updates on Provider’s safety strategies including Sign Up To Safety

Healthcare associated infections

Safeguarding referrals and Serious Case Reviews

Care leaver support and transition planning

Saving Babies Lives Care Bundle

2. Effectiveness of care (which encompasses cost effectiveness, compassion, equality and diversity). Aspects of quality of care that will be under constant surveillance include:

Hospital level mortality indicators/reducing avoidable deaths


22

Learning Disabilities Mortality Review Programme (LeDeR)

Readmissions

NICE compliance including

National Audit including Sentinel Stroke National Audit Programme

Stopping over medication of people with a learning disability autism or both

Care, Education and Treatment Reviews

Getting It Right First Time (GIRFT) and engagement with other quality improvement programmes to reduce unjustified variation in clinical practice.

Appraisals, supervision and development of staff

Clinical Audit outcomes

Enhanced Health in Care Homes

Outcome measures

Pathway development

Research and development

Innovation and initiatives

Staff surveys including NHS Friends and Family Test

Just as important is the effectiveness of care from the patient’s own perspective which may be measured through patient-reported outcomes measures and patient reported experience measures (PROMs and PREMs). Examples include improvement in pain-free movement after a joint replacement, or returning to work after treatment for depression. Clinical effectiveness may also extend to people’s well-being and ability to live independent lives.

3. Patient/ service user/ carer experience (accessibility, acceptability and appropriateness)

Quality of care includes the compassion, dignity and respect with which patients are treated. It can only be improved by understanding patient satisfaction with their experience and to achieve this the CCG will consider a wide range of information including

Citizen and Public Participation and Empowerment-

Complaints, Concerns and Compliments

Parity of Esteem

Ombudsman reports

Care Quality Commission (CQC) reviews

Claims and Litigation

Patient, family and carer experience group updates

Innovation

Equality and diversity requirements

Patient related outcomes

Patient surveys including NHS Friends and Family Test

Patients, their families and carers want to be safe, to be listened to and involved in decisions about their care. The CCG will endeavour to meet these needs to make a difference for the patients.


23

The overriding aim is to achieve excellence and commitment to high quality clinical care and all the satisfaction that comes from doing the job well. Our commitment to quality is central to the CCGs values and we will not tolerate sub-standard care.

Patient Engagement

The aim of the patient engagement activity at the CCG is to now build on the work

completed as part of the Future Fit programme and to continue to develop those newly

forged networks, practices, and resources.

A key focus for engagement will be to support the commissioning function with each

programme of work having its own tailored communications and engagement plan, which

will include planned activity for patients. This work has already started on major

transformation projects such as the Shropshire Care Closer to Home Programme and

provides a valuable asset recording and documenting a wide-variety of activities. The

challenge this year will be to increase the reach and opportunities so new activity is being

planned to take the conversation out to people in a more pro-active way.

The aim this year is to bring greater cohesion to engagement activity across the CCG

through co-ordinating all activity into a corporate timeline to support implementation and

resource management.

Personal Health Budgets (PHB) - From April 2019 PHB’s must become the default operating model for all CHC homecare packages and builds on the existing legal right to have. People will know what their budget is, will be involved in personalised care and support planning and have greater control over how the budget is used, including the option of a direct payment. https://www.england.nhs.uk/publication/comprehensive-model-of-personalised-care/ PHB implementation is a focus area for SCCG in 2019 – 20. Options for holding the budget:

Notional budget

Third party budget

Direct payment

Progress towards implementing PHBs however has been slower than anticipated and in 2019-2020, the CCG, as part of its Local Offer will be setting out clearly defined milestones in order to deliver The NHS Comprehensive Model of Personalised Care with a particular focus on supporting people with a learning disability, autism or both to have a PHB.

https://www.england.nhs.uk/publication/comprehensive-model-of-personalised-care/

https://www.england.nhs.uk/publication/comprehensive-model-of-personalised-care/


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10 Technology Introduction - Digital Planning for the CCG The CCG will enhance the IT infrastructure also by migrating to a health and social care network connection. This will enable the CCG to utilise video conferencing and corporate functions that support working in a rural county. The CCG will look to identify ways to support the efficiency of the corporate environment and implement, with the support from NHS England, tools to assist with the commissioning functions of the organisation. The corporate digital strategy will move to an agile approach for workforce.

Primary Care technology and digital plans for 2019/20

The main focus for the primary care architecture will be to implement a full upgrade in the network that is in place within GP practices. The upgrade will enable the GP practices to fulfil the requirements set out within the Long Term Plan and GP contract to provide digital access to primary care. The migration to the health and social care network will increase the bandwidth in primary care but also with all organisations moving to the network there is greater scope for integration. The CCG is also hoping to identify applications that help GP practices function, piloting online consultation software and endorsing the new cloud technologies so that GP practices are able to deliver services within the increasing footprint and meet the demands of integrated pathways. With the deployment of the Care Closer to Home service, this will be the catalyst for the GP record sharing, this will bring forward the requirement for the local health care record to increase the quality of care and reduce admissions.


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11 Corporate Governance, OD and Risks Introduction Governance The main function of the CCG is to ensure that it has made appropriate arrangements to ensure it exercises its functions effectively, efficiently and economically and complies with such generally accepted principles of good governance as are relevant to it. The CCG continues to take its governance arrangements seriously and during the latter part of 2018/19 undertook a Governing Body Effectiveness review, facilitated by Deloitte. The outcome of this review will inform improvements to the way the Governing Body and its Committees undertake the business of the CCG and ensure evidence based and transparent decision making and use of public resources. During 2018/19 the CCG Constitution has been updated to ensure it reflects good practice. The relationship between the CCG Membership Body and the CCG Governing Body are defined in the CCG’s Constitution along with areas including our shared principles, leadership, fostering excellence, supporting the Governing body and education. All of these areas engender good governance and will continue to be guiding principles in 2019/20.

Organisational Development The CCG continues to focus on Organisational Development and in 2018/19 carried out its own staff survey to inform a refreshed approach to organisational development and the creation of a new Organisational Development Strategy. This strategy, championed by the CCG’s Lay Member for Transformation will aim to address key issues staff has raised via the survey. In particular the CCG will be focusing on training and development opportunities for staff. The CCG continues to hold regular staff briefings and these now incorporate a social element where different teams host the first section of the briefing. In addition the CCG will continue with its regular staff newsletter and its monthly staff hero award

Corporate Risks

Finance

There is a risk that we will fail to achieve our planned control total

Quality and Safety

There is a risk that we will fail to commission safe, quality services for its

population

NHS Constitution

There is a risk that we will fail to meet our NHS Constitution targets either fully or

sustainably

Transformation

There is a risk that we will fail to effectively lead transformation of local

health services across acute, community and primary care to ensure

sustainability for the future


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Communication and engagement

There is a risk that we will fail to effectively engage and communicate with our

members, the public, partners and stakeholders and our staff

CCG workforce resilience and trust

There is a risk that the current financial situation will impact negatively on

existing staff resilience and retention levels and prevent successful delivery

Provider workforce

There is a risk that providers’ ability to deliver services and remain

financially viable is not sustainable

Stakeholder and patient support and trust

Failure to maintain stakeholder (including membership) and patient/public trust

and support leading to negative organisational reputation because of the following

reasons-: 1) financial performance challenges 2) leadership challenges 3)

organisational culture challenges 4) NHSE CCG assurance - 'needs improvement'

Legal directions

There is a risk that we will fail to have NHS England Legal Directions revoked

within an agreed time frame

Impact of social care funding challenges.

There is a risk of individuals escalating into acute hospital care or not being

able to be discharged from acute hospital care, thus impacting adversely on

the capacity and capability of health services.

Impact of sustainability of local Out of Hours provider

The CCG will not be able to commission a sustainable and cost effective out

of Hours provider in the future


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Summary Shropshire CCGs Operating Plan for 2019-20 set out the range of activities the CCGs is planning to undertake during the financial year. The plan has been set in the context of the emerging ambitions for the wider health and social care economy, whilst continuing to deliver the business as usual of the CCGs. The financial and challenged performance status of the CCG and economy should help drive some of the ambitions set out in the plan, and where possible accelerate schemes to ensure in year delivery of QIPP and transformation plans. The 2019-20 Operating Plan for Shropshire CCG is a component part of the Shropshire and Telford & Wrekin STP Operational Plan, where emergent themes has been localised to the CCG.

System Operational Plan April 2019 Shropshire, Telford & Wrekin STP Board Version of submitted STP Plan Our system plan has input from the following System Partners as well as wider stakeholders

2 |

Contents

Section Slides

1 Foreword by the Chair 3

2 Context, Challenges & ICS Development 4-7

3 System Structure, Governance & Performance 8-14

4 System Ambitions & Priorities 15-21

5 System Delivery Programmes 22-34

6 System Enablement Programmes Workforce, Estates, Digital, Comms & Engagement

35-43

7 System Activity & Capacity Planning 44-48

8 System Finances 49

Foreword by: Sir Neil McKay, Shropshire, Telford & Wrekin STP Independent Chair

This 19/20 system operating Plan forms the first year of our refreshed STP LTP due in the autumn 2019.

The Shropshire, Telford & Wrekin STP have worked collaboratively to bring single organisational operating plans from all system partners, including Local Authority plans in to an aligned narrative description that captures the following:

• System Priorities& Deliverables

• System understanding of activity assumptions

• System understanding of capacity planning

• System understanding of strategic workforce planning

• System Financial understanding and agreed approach to risk management

• Understanding of efficiencies and our collective responsibility to deliver those.

In order to develop from an STP to an Integrated Care System, we are required to structure and manage ourselves differently going forward.

Our system will make better use of our collective data to inform the initial Bronze Data Packs and later in the year the Population Health & Prevention Dashboard, both designed to improve our system business intelligence, understanding and planning for improved outcomes.

As part of our LTP refresh, our system will be revisiting our ambitions and the expected outcomes for our population served. In conjunction with our local authority colleagues, we will focus on developing Place Based Integrated Care, ensuring quality services are supporting health and wellbeing, whilst improving health inequalities.

Details of these will be available in our LTP later this year.

• System leadership capacity & capability across all organisations is fundamental to our success and we will be completing two key programmes to support our strategic development in this area:

• System Commissioning Capability Programme

• System ICS Development Programme

• Transformation across all that we do to achieve ICS status by 2021/2022 is our goal. Our focus will be on system delivery and enablement to achieve high quality outcomes for our population whilst making best use of our collective system resources in order to get best value for every £ spent.

• System financial recovery is inherent in all our ambitions and plans and we are implementing a structure to support delivery of efficiencies.

• The Long Term Plan refresh is our opportunity to work as a system, to meet our challenges of a growing elderly population with increasingly complex needs. Our system expertise (health, social care & wider stakeholders) will come together via our system Clinical Strategy Group that will in turn inform our System Programme Delivery Group, this will be the engine room of our system transformation.

• This plan has the support and sign-off through all our system partners via System Leadership Group and corresponding individual organisational governance processes.

• Finally, this plan demonstrates how we will improve performance, quality, integrated place based working and financial recovery through 19/20.

Sir Neil McKay, Independent Chair

Shropshire, Telford & Wrekin STP

2. Context, Challenges, & ICS Development

5 |

Shropshire, Telford & Wrekin STP local context

• Shropshire, Telford & Wrekin STP can be characterised as a good place to live and work, with a good sense of community and volunteering, and the population we serve recognised as diverse, with challenges set by our geography and demography.

• Shropshire is a mostly rural county with 35% of the population living in villages, hamlets and dispersed dwellings; a relatively affluent county masks pockets of deprivation, growing food poverty, and rural isolation. Telford & Wrekin is predominantly urban with more than a quarter living in the 20% most deprived nationally and some living in the most deprived areas.

• The STP sits between some of the largest conurbations in the country (Birmingham to the South, Manchester and Merseyside to the North), as well as sharing its western border with Wales.

• The STP footprint is served by one acute provider (Shrewsbury & Telford Hospital NHST), one specialist provider (The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS FT) , one community health provider (Shropshire Community Health NHST) and one mental health provider (Midlands Partnership FT) The ambulance provider is West Midlands Ambulance Service FT.

• There are two CCGs across the footprint; Telford & Wrekin CCG has a large, younger urban population (173k) with some rural areas and is ranked amongst the 30% most deprived populations in England. Shropshire CCG (308k) covers a large rural population with problems of physical isolation and low population density and has a mix of rural and urban ageing populations.

• There are two corresponding local authorities in the footprint; Telford & Wrekin Council, and Shropshire Council

• There are two A&E sites within 28 minutes drive time of each other (Royal Shrewsbury Hospital and Princess Royal Hospital), both with growing volumes of attendances, regularly seeing 400-430 attendances across both sites each day.

• Residents of parts of the footprint will have reasonably long drive times to access acute services. • The nearest major trauma centre is at Stoke on Trent (UHNM), in the neighbouring Staffordshire footprint. • There are some high prevalence rates of mental health conditions identified in Shropshire, T&W; there is one

mental health provider with a full coverage of services available within the footprint. In addition to minimum Tier 3 and 4 inpatient wards, specialist beds and Tier 4 secure/forensic services are provided.

• Shropshire/T&W has a good relationship with care providers facilitated by Shropshire Partners in Care (SPIC)

6 |

System Challenges One of the significant challenges facing our system is the cultural shift required to move from overly medical care models to ones that align with the principles of prevention, self-help and early intervention. This applies equally to mental and physical health care, as does ensuring parity between physical and mental health care. Another challenge we face is that the system has struggled to make the cultural adjustment needed toward integrated working; this has been exacerbated by insufficient access to a substantive workforce which has impacted on quality, performance and finances. There are also reducing budgets in the care sector and complex political relationships across the system.

Demographics & geography:

• Ageing population: in the Shropshire Council area, 23% of the population is 65 years and over compared to the England average of 17.6% . T&W Council area has a greater number than average of young people but a rapidly growing older population.

• A largely rural Shropshire in contrast with a relatively urban T&W provides challenges to developing consistent, sustainable services with equity of access.

• Shropshire, T&W STP area can be described as a low wage economy; consequently the wider determinants of health including education, access to employment and housing are significant issues to consider when developing services that support good physical and mental health.

Operational performance

• A&E: workforce constraints with consultant and middle tier medical and nursing staff vacancies at SaTH have affected performance, with year to date 4-hour performance at 75.87%

• Cancer: the system is failing to deliver consistently against key cancer standards in all specialties due to challenges with staffing combined with high numbers of referrals

Financial position – the system is facing in year financial pressures:

• At the time of writing this plan, there remains a material gap from the collective Control Total of £21m deficit , driven largely by financial challenges within Shropshire CCG and Shrewsbury and Telford Hospitals Trust. This represents a deficit across the system of £48.6m, with a risk to delivery of £23.2m.

• The two local authorities have been required to make significant savings over recent years, compounded by significant rising costs in delivering social care for both children and adults.

Workforce

• All providers (including the social care and domiciliary sector) report issues recruiting qualified staff due in large part to the geography and demography of the area.

Quality • Shrewsbury and Telford Hospital NHS Trust has recently been rated ‘inadequate’ by CQC and is in ‘special measures’, due to quality and leadership. The Trust is involved in an ongoing independent review into neonatal

and maternal deaths. • Shropshire Community Health NHS Trust is rated as ‘requires improvement’. The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust is rated as good.

• 88% of care homes in Shropshire are rated good by CQC, as is the mental health care provided by MPFT (Midland Partnership NHS Foundation Trust)

• Healthwatch Shropshire and T&W both work to support and identify areas for quality improvement in our STP Footprint

Reconfiguration

• Public consultation on acute services reconfiguration (‘Future Fit’) completed; Final Decision Making Business Case approved by Joint Programme Board January 2019. Implementation over the next 5 years, subject to NHSI approval.

• Closer joint working between the two CCGs, exploring the options to move to a Single Strategic Commissioner. Interim Accountable Officer appointment for Shropshire County CCG commenced April 2019, following retirement of the incumbent.

• Midwifery-Led Units case for change just completed NHS England strategic sense check ahead of proposed reconfiguration consultation

7 |

Development towards an Integrated Care System

• STP System Leadership are progressing towards an Integrated Care System with aligned strategic thinking and delivery.

• Shadow ICS board currently being developed

• Renewed Governance and leadership

• STP governance refresh (in progress)

• Commissioning Capability Programme

• Development of strategic commissioning and wider partner engagement to shape together

• Strengthening the profile of mental health across the system

• Integrated Care Development Programme

• Integrated Care System Development (ICSD) - A programme to develop long term behaviors and capabilities to progress the development of local ICS architecture.

• Commissioning in our 'ICS System’ commissioning arrangements to support our wider objectives in order to transform the quality of care delivery and improve health and wellbeing for our population.

• Functions of the CCGs

• Services the CCG provide

• Teams are in the CCG and what are their areas of expertise

• Merging STP/CCG resources where possible

• Understanding the optimal level/scale at which to commission and where greater efficiencies can be sought.

• National Delivery Unit Data pack (Bronze Packs) - a standard data analytical pack produced from national data sources provided to system to identify system opportunities that will contribute towards financial sustainability and improved health and wellbeing outcomes.

3. System Structure, Governance & Performance

Future governance

• The current STP governance is a partnership between all current organisations in the system. Partners are prioritising the 2 key work programmes:-

1. System Commissioning Capability Programme

2. System ICS Development Programme

• We are also committed to working across the system on our Integrated Place Based Care Programme

• During 2019/20 we will design new system structures, including a ICS Strategic Commissioner and Place Based Alliances and the governance will evolve.

• The benefits will be:-

• System efficiencies

• System focus on Health AND Social Care

• One strategic commissioner organisation able to drive improvements in performance and quality of care consistently to meet NHS constitutional and key Local Authority targets

• Stronger local (place) arrangements to deliver care closer to home, as per Future Fit and individuals aspirations/wishes

• Local synergy with other initiatives including development of Primary Care Networks, Population Health Management and wider prevention.

Refreshed System Governance (to be agreed)

The refreshed governance structure is currently being developed at the System Leadership Group (SLG) this will ensure a streamlined approach to our system transformation programmes this includes - • Agreed standardised principles for

each transformation workstream

• Strategic oversight for all programmes • Specific Terms of Reference and

membership for each workstream • CEO/AO lead for each programme • Dedicated Programme Management • Contributes to the LTP • Contributes to the implementation of the

delivery plans • Each programme will have a clinical

presence • Quarterly Transformation checkpoint sessions • Monthly Operational plan delivery meetings • Quarterly Chair oversight meetings • Monthly ICS Shadow board meetings to review

and support each programme

Operational Plan Delivery Group

Commissioning Capability The system is currently considering the WSOA data pack (Bronze Pack) through the System Commissioning Capability Programme that includes health and local authority colleagues. Through this programme we are developing the skills and competencies that underpin the implementation of the MCFR Framework. This should position commissioners to fully support transition to the ICS. Expected outcomes: • All system efficiencies to be considered and actioned as agreed with system partners • All efficiencies to be included in system financial position • All risks to delivery to be identified and mitigated with system partners • Population Health & Prevention Dashboard to be delivered later this year (expected

Autumn 2019)

Governance Delivery of the agreed Operational Plan will require robust integrated working across the whole system. To facilitate this the SLG have agreed an Operational Plan Delivery Group, which will be chaired by the STP Sustainability & Transformation Director and include senior Operational, Finance and Clinical representatives from each partner organisation. This Group will: • Monitor delivery against key milestones and performance targets • Provide system support to collectively identify and implement mitigations required to

ensure delivery of agreed plans • Ensure balance of operational, financial and quality performance is maintained across

the whole system

Implementation of this Group has been agreed in principle by SLG. We are progressing development with the support of nationally available programmes and resources.

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Key System Drivers / Summary Hypotheses

Shropshire and Telford & Wrekin STP Diagnostic: System Opportunity Overview – Bronze Pack

MSK is the second highest area of spend for the STP, c.£50m. Spend is c.£10m higher than the national average rate (2017/18).

Elective spend for MSK is higher compared to peers, a difference of £8.5m. c.87% of this spend (c.£7.4m) relates to Shropshire CCG (2017/18).

The STP prevalence of obesity (18+), 10.8% is higher than the England average (9.8%) (2017/18). The percentage of physically inactive adults in Telford (30.3%) is higher than the England average 22.2% (16/17).

21.5% of the STP population reports a long term MSK problem, higher than the England average of 18.5% (2018).

Shropshire CCG has a higher number of bed days for MSK compared to peers, a difference of 3,517 bed days (2017/18).

Shropshire CCG has a higher number of MSK long stay patients (21+ days) compared to peers, a difference of 17 patients (17/18).

For Robert Jones and Agnes Hunt Hospital elderly medicine the % of day cases to all elective activity in elderly medicine is 31%, below peer median (56%); median LoS for elective admissions is 2 days, below peer median (3) (Aug 18).

The median length of stay for emergency admissions (elderly medicine) was higher than the peer median (6 days) for Robert Jones and Agnus Hunt NHS Trust (9 days) (Aug 2018).

The percentage of total STP elective MSK services sent to the independent sector, 9.6% is below the national average (21.7%). There is geographical variation with Telford & Wrekin sending a higher percentage than the average (25.7%) and Shropshire a lower percentage than the average (2.3%) (17/18).

The percentage of the STP’s population aged 60-79 (22%) is higher than the England average (18%) and the growth rate for this segment is 6%, also higher than average (2%). The percentage of population aged 80+ (6.2%), is higher than the average (5%) and sees a growth rate of 2.4% against an average of 2.4% 2016.

The STP spend on social care needs is c.£6m lower than the national average (spend per head rate). CHC spend is c.£0.2m higher than the national average per 50,000 population at a STP level, however c.£1.2m lower per 50,000 for Telford and Wrekin CCG (2017/18).

Potentially avoidable attendances at A&E referred from elsewhere in the system are c.45% higher compared to peers, corresponding to a potential opportunity of 5,038 attendances compared to the best 5 peers (2016/17 Q4 - 2017/18 Q3).

Non-elective admissions per 1,000 are c.7-14% higher compared to the 5 best peers, a potential opportunity of 5,360 admissions. Non-elective bed days are c.12% higher for Shropshire CCG compared to peers, a potential opportunity of 19,043 bed days (17/18).

The proportion of patients discharged to their usual place of residence is c.7% lower compared to peers for Shropshire CCG, a potential opportunity of 758 discharges (2016/17 Q4 - 2017/18 Q3).

The proportion of continuing healthcare eligibility decisions made within 28 days of the initial referral is below the England average for both CCGs and lower compared to peers - a potential opportunity of 216 decisions compared to the 5 best peers (2017/18).

There has been a decrease in the percentage of people in Telford & Wrekin (over 65) still at home 91 days after discharge from hospital between 16/17 (71%) and 17/18 (62%).

Circulation and respiratory are the third and fourth highest expenditure areas in the STP (c.£84m in total). c.£3.5m more is spent on circulation and c£3m more on respiratory compared to national average rate (2017/18).

Non-elective spend on circulation and respiratory is higher compared to peers, c.£2.5m and c.£3.4m respectively (17/18).

Compared to peers, there is a potential opportunity to detect more patients with hypertension (5,640), coronary heart disease (3,128) and chronic obstructive pulmonary disease (2,279) (2016/17).

There are opportunities compared to peers to improve circulation quality and outcome indicators including the % of hypertension patients with BP >150/90 (2,686) (2016/17).

There are opportunities compared to peers to improve across respiratory quality and outcome indicators including the uptake of over 65s receiving the PPV vaccine (2,605 patients) (2016/17).

Compared to all local authorities, Telford (123/149) is in the bottom quartile for tobacco control (smoking prevalence and smoking status at time of delivery) and Shropshire (103/149) is ranked “worse than average” (2016/17). Shropshire Council is 145th and Telford & Wrekin Council 96th out of 149 LAs for drug treatment summary (2016/17).

The number of bed days is higher compared to peers for respiratory (6,170 days) and circulation (1,900). The number of long stay patients (21 day +) for Telford CCG is higher compared to peers for respiratory (27) (17/18).

Respiratory mortality is higher for Shropshire CCG compared to peers, with a potential opportunity of 43 patients (2012-14).

Out of Hospital Care Lower social care and CHC spend, higher avoidable

admissions and delayed discharged, with longer LoS for the elderly

1 MSK

Higher spend on MSK, widespread risk factors, higher prevalence and number of bed days/LoS

2 Prevention and Detection

Lower rates of detection, higher non-elective spend on circulation and respiratory services

3

• Mental health c.£59m, c.£15m less than the 17/18 national average (spend per head rate). • The dementia prevalence (Shropshire CCG) 1.09% is in the highest quartile (16/17). • The dementia diagnosis rate for Telford CCG, 65.9% is lower than the national

average (67.8%) (Aug 2018) • MSK c.£50m, c.£10m more than the national average.

• Fracture, hip and thigh, 3rd highest admission from care home • The percentage of STP population reporting a long term MSK problem, 21.5% is

higher than the England average (18.5%) (2018). • The STP prevalence of obesity (18+), 10.8% is higher than the England average

(9.8%) (2017/18). • Circulation c.£42m, c.£3.5m more than the national average.

• £0.73m opportunity for respiratory primary care prescribing (2017/18). • Non-elective spend on circulation and respiratory is higher compared to peers, a

difference of c.£2.5m and c.£3.4m respectively (17/18). • The number of bed days is higher compared to peers for respiratory (6,170 days)

and circulation (1,900) (17/18). • Respiratory c.£40m, c.£3m more than the national average. • Gastrointestinal c.£35m, c.£1m less than the national average. There is lower spend for social care needs (c.£6m) and maternity and reproductive health (c.£3m) compared to the national average rate. Public health indicators key highlights: • Healthy Life Expectancy in T&W significantly lower than Shropshire and lower than the

national average • Smoking at tine of delivery higher than national average Shropshire and T&W • Obesity – adults higher than national average for both Shropshire and T&W, Children –

higher than national average at reception (Shropshire), yr 6 T&W • Prevalence of diagnosed hypertension all ages Shropshire higher than national average,

T&W similar • Alcohol harm T&W higher than national average

Area Indicator England Shrop CCG T&W CCG

Elderly pop % % aged 60-79 18% 24% 19%

% aged 80+ 4.9% 6% 4%

Growth rate of Elderly pop

Annual growth pop 60-79

1% 2% 2%

Annual growth 80+

2% 3% 3%

Using system data to drive system change - Bronze Pack

CCG/Area No. of GPs (WTE) GPs per 10,000 Pop (HC)

% GPs over 55 % GPs over 65

Sept 15 Sept 18 Sept 15 Sept 18 Sept 15 Sept 18 Sept 15 Sept 18

Shropshire 194 202 8.0 8.5 21% 20% 0.5% 1.5%

Telford & Wrekin 103 101 5.9 6.4 17% 18% 0.5% 2%

North Midlands DCO

2,583 2,372 7.0 7.5 17% 18% 3% 3%

Using system data to drive system change - Performance

4. System Ambition & Priorities

16 |

System Leadership statement – agreed April 2019 (to be further refined and built upon as part of LTP refresh)

“The ambition of Shropshire, Telford & Wrekin STP is to deliver joined-up, transformed health and care services for local people.

Our focus for the next 5 years will be to work with primary and community care, hospital services, social care, independent providers and the voluntary and community sector

to deliver services at a place level; ensuring that local needs are understood and addressed with people being cared for and able to access services and support as close to where they live as possible”

To achieve this : We will deliver our transformation in partnership across our organisations, working with our staff, engaging our population, and by setting good policy and outcomes frameworks. Do all we can to listen to and understand the needs of our communities and staff. Work together, utilising all our collective resources, to provide quality services and support. Use data, evidence and insight to underpin decision making at every level

STW Ambition Statement

Shropshire, Telford & Wrekin, Priorities, Linked to the Long Term Plan

Programmes and Priorities: Population health and wellbeing • Working across health, care and the VCSE, to

proactively support people to improve and maintain their health & wellbeing

Integrated Community Services • Boosting ‘out-of-hospital’ care and

dissolving the divide between commissioning and providing as well as primary and community health services

• Integrated working (physical, mental health and social care) working and primary care models; implementing multi-disciplinary neighbourhood care teams

• Ensuring all community services are safe, accessible and provide the most appropriate care.

Acute & Specialist Hospital Services Redesigning and delivering urgent and emergency care, creating two vibrant ‘centres of excellence’ • Delivering high quality, safe services • Transforming and digitizing

Enabled by: Strong partnership working across health, care, public, private and voluntary and community sector

Making the best use of technology to avoid people having to travel large distances where possible

Communicating with and involving local people in shaping their health and care services for the future

Supporting the workforce to be a highly responsive, happy, confident and capable workforce that provides excellent quality services, in the right place with the right skills, ensuring the workforce engages with local opportunities for the future

Improving and making more efficient our back office functions

Making better use of our public estate

Outcomes: - Improved healthy life expectancy - Improved system efficiencies - Increased partnership working across all

delivery & enablement programmes - Living independently at home for longer

Measured by: Quarterly Checkpoint review meetings • Bronze pack/ right care • Public Health Outcomes Framework • Delivery Programmes • Enablement Programmes

Governed by : (proposed) System ICS Shadow Partnership Board • Shropshire CCG • T&W CCG • Shrewsbury & Telford Hospital • Shropshire Community Health Trust • Robert Jones and Agnes Hunt • Midlands Partnership Foundation Trust • Shropshire Council • Telford and Wrekin Council

Cancer Maternity and Paediatrics Stroke/ Cardiology Ophthalmology Mental Health

Outpatient care MSK ENT Respiratory Elective Care

April May June July Sept Oct Nov Dec Jan 20 Feb 20 Mar 20

ICS Development Programme start

Updated enabling strategies: Workforce, Estates, Digital, Comms and engagement

5 year plan submission

Commissioning Capabilities programme

Start Jan 19

Clinical Strategy Group Refresh

Population Health Management and Place Planning

ICS Development Workshops

ICS Shadow Board

Start (in May/June) of Operational Plan Delivery Group (Financial Recovery and performance management)

Continued integrated development through 19/20

ICS Board

Integrated/ aligned STW out of hospital programme (including PCNs)

System development and governance 19/20; key highlights

April May June July Aug Sept Oct Nov Dec Jan 20 Feb 20 Mar 20

Transforming maternity services consultation

Ph 2 - Case management pilot implementation

Ph 3 Integrated care teams pilot implementation

CYP Mental Health Transformation programme: ongoing

Ongoing 19/20

5 day delivery Frailty Front Door – PRH

Expected start of Sustainable services/ Future Fit implementation

Establishment of Primary Care Networks

Implementation of DES, extended hours, & 25% online booking

Ph 2 - Case management implementation evaluation

Ph 2 - Case management full implementation

T&W - Integrated team around Primary Care Networks pilot (incl. Social care, MDTs )

Pilot integrated care record

GovRoam – all partners sites and devices connect on wifi

EPR for SaTH implementation agreed

Maternity services pilot continuity of carer programme

T&W - Development of risk stratification – IG starting Q1 implementation through Q4

Joint all age Mental Health Strategy

System implementation timeline; key highlights

MSK Evaluate SOOS & TEMS

Improving ED systems & processes



The system has a shared approach including:

• Individual Safety

• Individual & Patient Experience

• Effectiveness

• Well- Led

• Sustainability

• Equitable for all

System approach to Quality As a system we are committed to working together to:

• Improve the issues facing quality, safety and patient experience management

• Operationalise the local quality and assurance framework across all providers

• Drive actions required to address concerns on the quality risk register

• Drive the Enhanced health in Care Homes framework

• Complete Equality, Quality Impact Assessments at the start of commissioning and decommissioning processes.

• Review Root Cause Analysis of Serious Incidents and Never Events to ensure learning is shared across all agencies to drive forward service improvements and patient safety

• Escalate quality concerns and reports to Board, QSG, NHSE and NHSI as required

• Develop a robust Quality Strategy with clearly identified priorities and that takes into account the full system, health and care

• Use all available resources including Right Care Opportunities to deliver improved quality by removing unwarranted variation and improving outcomes at a population health level How we are working together as a system

• Shropshire LA and T&W LA address quality across commissioned services through contract monitoring in conjunction with CQC and Healthwatch

• Shropshire CCG and T&W CCG quality teams working together to address quality across commissioned services to further increase effectiveness, integration and alignment is being planned

• Quality leads are aligned to each provider contract linked with performance, contracting and finance leads with ‘buddying’ arrangements in place across the two CCG quality teams

• The quality and safety of provided services is assured through quality schedules, commissioning for quality and innovation indicators (CQUIN), monitoring of the quality impact of cost improvement schemes and site visits of major providers.

• Quality exception reports are received and discussed monthly at Board.

• Quality dashboards are monitored with named quality leads aligned

• Quality leads are aligned to each QIPP and finance leads.

• Service development programme linked with performance, contracting and a programme of site visits is in place

Our Drivers for Quality include:

• Francis Report • Berwick Report • National Quality Board • NHS Outcomes Framework • Care Quality Commission Essential

Standards • NHS Assurance Framework • CCG’s Improvement & Assessment

Framework • NHS 10 Year Plan • ASC outcomes framework • Public Health Outcomes Framework

Aspiration - Creating outstanding quality by: • Culture change within our organisations to work in an integrated way, reducing

medical models of care when appropriate, and supporting people in their community, delivering the best possible care and support for our population (inclusive of Social Care, Dom Care and Private Providers)

• New dynamic that strengthens communities and individuals ability to self-care • Patients are at the centre – to sustain and improve primary care, including

strengthening integrated multi-disciplinary working ensuring people stay at home

• Streamlined care, robust pathways – to ensure we commission sufficient capacity for planned care and improve patient experience of appointments

• Support people in crisis with the right care at the right place – to make sure people can navigate a simplified urgent care system to meet both physical and mental health needs

• Aspiration that all providers to reach outstanding levels of care for our communities

System Quality Focus

Approach to improving quality at SaTH Delivering against our Must Do actions from the CQC inspection – specific focus on ITU, ED, Maternity Improving ambulance handover time in ED Reducing Corridor Care in ED Improving Ambulatory care to reduce unnecessary admissions Improving frailty pathways Improving discharge to reduce unnecessary Length of stay and reduce further patients that stay in hospital over 7 and 21 days Maintaining Day Surgery capacity throughout the year in order to reduce waits for surgery Improving workforce numbers through international recruitment for nursing and medical staff Improving staff experience and well being through delivery of the OD plan

Addressing Immediate

requirements

Whole system quality strategy

System quality monitoring ICS

Continuous improvement

STW Process to improve quality

Workforce • Key challenges:

• Staff retention and recruitment

• Cultural challenges within existing organisations and staff groups resistant to change; preparing a workforce with no boundaries across organisations

• Cultural change to support out of hospital working

• Cultural change to embed prevention, self-care utilisation and health coaching

• Reducing dependency of bank and temporary staffing • Key priority areas-

• Recruitment and retention, education, training and staff development

• Leadership, culture and organisational development

• Workforce information, planning and intelligence

5. Delivery Programmes

DRAFT - Vision of STW Integrated Support and Care Approach

As a STP we are developing a visual representation of how we are working in an place based integrated way; working in collaboration across organisations and with our communities.

This diagram is a draft of our joint vision that will be further developed for the 5 year plan.

24 |

Priorities: 1. Develop system architecture for population health, including a robust understanding of need through business intelligence and the JSNA 2. Working with the regional support offer to develop capacity and capability across Shropshire 3. Support improved working for prevention across all organisations; in particular

• Embedding prevention through transformational work programmes, in particular Primary care and Community services • Develop our wider workforce in behaviour change and motivational interviewing • Proactively identify people at risk of ill health and behaviour change conversations, brief interventions • Prevent harm due to alcohol, obesity, CVD and poor mental health • Support culture change and new working practices that help people at the earliest opportunity • Support active signposting and develop a good understanding of how communities support people – linking to Social Prescribing • Work across organisations (including the VCSE) to prioritise support for key population groups – address inequity and inequalities by connecting with the national

and regional population health management support mechanisms

Population health and prevention

Deliverables: • Working with the regional support offer, deliver a prototype using the population health management approach to improving care • Deliver system data repository, JSNA development and reporting processes • Support for place based working with the local authorities (connected to primary care and community transformation); • Deliver Stop smoking services for patients, expectant mothers, long term users of specialist mental health services and learning disabilities; • Implement social prescribing, targeting CVD and weight loss services to people who need it most; • Deliver greater uptake of the National Diabetes Prevention Programme; • Ensuring children have the best start in life including access to mental health and early help support; • Establish alcohol care teams in hospital and community

25 |

Primary care

Priorities: 1. Developing Primary Care Networks and New Models of Care (including the development of Care Closer to Home and Neighbourhood working) 2. Prevention and addressing Health Inequalities 3. Care Quality and Improvement 4. Improving Access to Primary Care – 7 days a week 5. Ensuring a workforce fit for the future 6. Improvements to technology and digital enablers 7. Ensuring high quality estate 8. Optimising workflow and addressing workload pressures in Primary Care 9. Ensuring quality and efficiency in prescribing

Deliverables: • 100% coverage of Primary Care Networks by July 2019 including delivery of the extended hours Directed Enhanced Service • Increase uptake of physical health checks and dementia diagnosis rates • Meet the 7 core standard required in the extended access enhanced service including direct booking via 111 • Improvements to technology, digital enablers • Deliver retention and recruitment programmes to secure a primary care workforce fit for the future including the enhancement of the primary care training hub • Meet the required additional clinicians programme as outlined in the Long Term Plan .e.g social prescribing link workers and clinical pharmacists • Deliver the requirements of use of technology e.g. 25% of appointments available online by July 2019, electronic repeat prescribing, implementation of the NHS App • Completion of primary care estates review and full alignment with One Public Estate programme • Delivery of the 10 high impact changes to support workflow optimisation • Reduction in antimicrobial resistance and medication errors. Increase use of generic medicines and prescribe according to best practice

26 |

Priorities: • Developing a joint out of hospital integrated services that support the diverse population we serve; working collaboratively with Community Services, Acute Care,

Primary Care, Social Care, Preventative services, and the VCS; this includes: • Integrated Place Programme ( T&W) • Care Closer to Home (Shrops)

• Phase 1 – Frailty at the Front Door (hospital service approach), Shropshire in progress, T&W in planning , delivery estimated June 2019 • Phase 2 – Case management through demonstrator sites - Shropshire , June 2019 • Phase 3 – Community services including admissions avoidance and delayed transfers, Autumn 2019

• Using data to drive the development of services (including case management and prevention services) • Delivering admission avoidance , in reach and facilitated early discharge • Developing joint personal health budgets governance and delivery with the Local Authorities • Develop joint processes and commissioning for CHC (health and care) • Connect social prescribing with out of hospital and primary care transformation programmes (Care Closer to Home and Neighbourhoods), and the Better Care Fund

prevention strands and voluntary sector grants and contracts

Deliverables: • Supporting the development of resilient communities, prevention and early help in conjunction with all partners • Upscaling ‘Frailty at the Front Door’ to implement in PRH (already delivering in PRH) • In collaboration with system partners, development and delivery integrated care models, including:

1. Risk Stratification and case management 2. Rapid Response 3. Intermediate care/ hospital at home 4. Care home support (including Care Home Advanced, Trusted Assessors, Care Home MDT) 5. Social Prescribing and prevention services

• Implement an aligned programme across T&W and Shropshire • Implement a robust system and governance for personal health budgets • Implement new practices for jointly delivering CHC with local authority partners • Progression of models of Social Prescribing by joining with out of hospital with additional funding, in connection with primary care and the local authorities • Connect with data and infrastructure developments as part of Population Health Management programme

Out of hospital integrated care (including personalised health budgets and social prescribing)

27 |

MSK Transformation Programme

Priorities: • Ensure the model, priorities and resources relating to the vision and objectives for the MSK transformation programme • Ensure there is strong patient and public engagement in the MSK Transformation programme • Ensuring that an over-arching Communications and Engagement Strategy is in place and that key messages are circulated to partner organisations following each meeting. • Ensure changes to the MSK services in Shropshire are based on clinical evidence and best practice (national and international) • Monitor the impact of the transformation programme including unintended consequences/dis-benefits, and agree on an appropriate strategic response • Ensure effective coordination of the planning and commissioning of services and operational delivery with a robust supporting infrastructure • Engage with GP Clinical Directors, Academic Health Science Networks, inviting their representatives to attend Board meetings, as appropriate. • Engage with clinical/operational teams to ensure all staff are aware of the strategy and their input required • Review MSK services within community and secondary care; • Transforming operational processes and developing a single service model for the whole MSK pathway, using the results of the review and the First Contact Practitioner pilot evaluation; • Delivering referral targets; • Delivering quality and financially sustainable services.

Deliverables: • Establish STP MSK Programme Board • Assess current delivery of services including TEMS (evaluation of SOOS completed with a provider review planned in the next 6 months) • Assess resources for delivery – alignment of existing CCG and provider resource following the receipt of an agreed gap analysis • Review current delivery board membership to ensure that the appropriate level of decision making can take place • Scope of services to be determined within the agreed resource envelope • Impact analysis throughout of implementation/changes • Demand and capacity assessment of existing providers • Development of a strategy to possibly consider the option to move to one integrated MSK provider • Consider and support where necessary the reconfiguration and transformation programme to ensure the sustainability of services • Review GIRFT outputs, Right Care and data sources to support changes/redesign • Development of an agreed delivery outcome frameworks • Completed MSK review; • New single service model for MSK that integrates with community and secondary care; • Continue to monitor progress and quality

28 |

Priorities: • Improve Safety

• Stillbirths and neonatal reduction • Reduction in brain injury

• Improve Choice and personalisation • enabling all women to have a personalised care plan and choice in the care they receive

• Increase midwife led births • increase the number of women giving births in a Midwife led unit

• Increasing investment in perinatal mental health • Develop continuity of carer

Deliverables: • Develop and progress the Midwife Led Unit Review • Develop and implement pilot for continuity of carer programme • Fully implement improvements in safety including Saving babies lives care bundle • Deliver improvements in choice about maternity care, including by developing personalised care plans • Implementing the neonatal quality improvement programme • Develop workforce plan to improve core staffing with clear governance and reporting • Developing a culture of learning and improvement

Local Maternity System

LMS Progress against KLOE 19 March 2019

2015

baseline 2018/19 2019/20 2020/21

2015

baseline

(and data

source)

Trajector

y March

2019

Trajector

y March

2020

Trajector

y March

2021

Change

in rate

2015 -

2020

Local

baseline

Trajector

y March

2019

Trajector

y March

2020

Trajector

y March

2021

Change

in rate

2015 -

2020

Local

baseline

Trajector

y March

2019

Trajector

y March

2020

Trajector

y March

2021

Local

baseline

Trajector

y March

2019

Trajector

y March

2020

Trajector

y March

2021

Local

baseline

Trajector

y March

2019

Trajector

y March

2020

Trajector

y March

2021

Local

baseline

Trajector

y March

2019

Trajector

y March

2020

Trajector

y March

2021

4887 4851 4827 4824 30 23 22 20 11 9 8 7 0 0 4827 4824 4887 4851 4827 4824 0 970 1,496 2,460 708 825 965 1,206

6.15/1000 4.8/1000 4.5/1000 (20%)4.2/1000 2.2/1000 1.8/1000 1.7/1000 1.5/1000 0% 0% 100% 100% 100% 100% 100% 100% 0% 20% 31% 51% 14% 17% 20% 25%

Number of births Number of women giving birth in

midwifery settings

Key Lines of Enquiry Key Lines of Enquiry Key Lines of Enquiry

Stillbirths and neonatal deaths Intrapartum brain injuries Number of personalised care plansNumber of women able to choose from

three places of birth

Number of women receiving continuity

of carer during pregnancy, birth and

postnatally

29 |

1. Workforce 2. Acute Care /Frailty Model 3. ED systems and processes Options being enacted to mitigate the challenges

• Frailty at the front door at PRH

• Protect Streaming workforce

• Plans in notes and clinical criteria for discharge

• Achieve Pre-12 discharge potential on all wards

• Achieve further reductions in length of stay by:

• Discharging patients requiring IV therapy to community slots

• Achieving the potential in PRH stranded patient reduction

• CDU capacity created in Head and Neck theatres at RSH from the 8th of April to release bed capacity in acute medicine.

• Space Utilisation prioritisation

• Workforce models to support the current workforce challenges

Options being enacted to mitigate the challenges-

• Achieve Acute Medicine and Ambulatory care potential (project group facilitated by ECIST commenced 14th March). This will require additional acute medical workforce.

• Recruitment of doctors from India and nurses from Southern Ireland

• Approval of workforce business cases for ED staffing and Acute Medicine staffing.

• Transfer of stroke neuro-rehabilitation to the community and further development of early supported discharge(Whole system approach)

• Development of cardiology SDEC /heart failure/respiratory acute (from 6 A’s audit).

• Development of cardiology direct access service (from 6 A’s audit).

• Development of ambulatory and 72 hour frailty service across both sites (requires workforce).

• Development of a 24 hour CDU model (requires workforce)

A&E performance and trajectory- 19/20 – Top Three Priorities:

30 |

The ambition for Urgent & Emergency Care is to: Provide enhanced system-wide urgent and emergency care that ensures our patients are cared for in the most appropriate setting by skilled workforce able to meet their needs, develop services that are based on best practice, demand and capacity analysis and the needs of our local population with an

overarching ambition to support all patients Home First. By working together as a system we will:

Urgent & Emergency Care

Prioritise: Improve care: Improve Experience:

1. ED Systems and Processes

We aim to implement standardised best practice, enhance our workforce and appropriate capacity to improve emergency care provision resulting in improved patient outcomes and satisfaction, appropriate staffing, capacity and improved recruitment and retention of skilled staff to meet the needs of our patients.

• Improved system working • Improved access to clinically

appropriate services • Reduced ambulance handover

time • Reduce ambulance conveyance • Reduced attendances and

inappropriate admissions • Increased number of patients

being treated in SDEC • Improved identification and

management of frail older adults • Increased home first • Improved patient outcomes • Reduced mortality and morbidity • Improved patient and carer

satisfaction • Improved team working and staff

morale • Meet the A&E 4 hour quality

standard to avoid waiting.

2. Frailty

We aim to have a fully functioning Frailty Front Door Service for 5 days a week at both sites by May 2019. We aim to extend this service to run 7 days a week by October 2019. We will work with the STP Out of Hospital Group to co-design a whole system frailty pathway and service model.

3. Ambulance

We aim to ensure that we maximise the opportunity to avoid conveyance to ED so that patients arriving by ambulance to ED are appropriate, and enjoy a seamless handover to ED without delay.

4. Acute Medical, Short-stay and Same Day Emergency Care (SDEC)

We aim to develop and implement an enhanced Acute Medical, Short-Stay and Same Day Emergency Care (SDEC) model based on national best practice and needs of the local population.

5. Care closer to home

We aim to enhance and embed ‘Home First’ services to enable all our clinically appropriate patients to be offered a home first solution that meets their needs.

6. Discharge management

We aim to ensure that patients stay in hospital for the minimum time required to manage their presenting problem while avoiding the secondary harms arising from hospitalisation and ensuring as soon as they are safe to transfer they have the opportunity to be discharged to their usual place of residence and / or access to step-down services for re-ablement which maximises independence is required.

31 |

Urgent & Emergency Care

Priorities: *continued from last year’s high impact changes • ED Systems and processes *

• Frailty at the front door *

• Ambulance Demand *

• Same Day Emergency Care/Acute Assessment/Short Stay

• Home First (Care closer to Home)

• Discharge Management

Enabling programmes: • Demand and Capacity • Improvement in Informatics

Deliverables: • Successful recruitment to the workforce • Improved patient outcomes • Reduced mortality • Reduced attendances and inappropriate admissions • Improved staff morale • Improved patient / carer satisfaction • Improving access to Same Day Emergency Care (SDEC) • Improvement and development of frailty at the front door programme • Sustained improvement in the reduction in long stays • Improving the data available and use effectively to inform clinical decision making and future priority planning • Improve discharge planning from moment of admission to prevent deconditioning and ensure a timely, home first approach for as many patients as possible • Improve ED systems and processes to ensure efficient and effective care for patients • Identify and manage constraints identified throughout the patient journey to ensure timely and effective care • Effectively match capacity and demand through the use of data and intelligence • Better use data to avoid conveyance and ensure patients are treated in the right place in the first instance. • Decreased deconditioning . Complications of hospitalisation will reduce • Meet the 4 hour A&E Quality standard.

32 |

Cancer Priorities: Ambition – fewer people to be diagnosed with preventable cancers; improve mortality rates and improve patient experience Priorities: • Deliver the Living with and Beyond Cancer; • Deliver cancer services that are accessible, timely and sustainable; • Workforce and capacity – testing new ways of system working that will deliver

more timely care; • Improve against performance targets; • Explore opportunities for improving urological cancer through joint working

across the system • In conjunction with the Cancer Alliance implement best practice pathways in

priority areas

Deliverables: • Implement a holistic needs assessment and care plan • Develop treatment summaries to guide patients and GPs post treatment • Develop and deliver the living well offer – providing advice, support and

signposting • Deliver the cancer care review – between the GP (or nurse) and patient • Deliver person centred follow – up tailored to the patients • Develop joint working processes for urological cancer • Develop a system wide cancer strategy • Implement best practice pathways for Lung, Prostate, Colorectal and Upper GI

Deliverables: • Monitor the acute trusts waiting list to ensure at the end of March 2020 does not exceed the waiting list

at the end of March 2018 • Work with providers to develop a process for identifying patients exceeding 6 months on the waiting list

and offering them an opportunity to move to an alternative provider • Develop a process for identifying patients approaching 40 weeks on the waiting list to ensure no patient

exceeds 52 weeks Outpatient Redesign • The CCGs plan to undertake a programme of work in relation to outpatients redesign. A task and finish

group has been established with SaTH & RJAH to look at what changes can be made. The CCGs intend to use this task and finish group to undertake the following actions:

• Identify area where non face to face appointments can be implemented • Explore areas where patient led follow ups can be implemented • Develop process for identifying unnecessary frequent attenders (such as mental health) and implement

mitigating actions for these patients • Align diagnostics with appointments • Use national outpatient improvement dashboard to improve clinic utilisation • Use the learning from the IBD app project to roll out to other areas • Identify technology opportunities in relation to outpatient appointments

RTT Priorities: • Streamlined care;

• Outpatient activity • Cancer treatment • Musculoskeletal (MSK) services • Neurology • Local Maternity Services

• Robust pathways; • Achieving targets

• 18 week referral targets – consultant lead treatment • 6 week diagnostic test target • 52 week treatment target

• Commission sufficient capacity; • Improve patient experience of appointments and treatments;

• Outpatient redesign

Cancer & Referral to Treatment

33 |

Mental Health (Children and Adults) and Learning Disabilities & Autism

Priorities: One of the key cultural challenges for mental health services is determining what mental health conditions should be treated in secondary services and what are treated within the community and primary care. Mental health services have been successful in moving from hospital/campus models of care to helping people recover in their own homes. We want to continue this through a choice of least restrictive environments and safe environments for short term interventions which the majority of people require. Equally, for those people who experience learning disabilities or autism, these long term conditions require access to both specialist and mainstream services where reasonable adjustments have been made to enable equality of access. Our priorities are: 1. Ensuring a great start for children and young people and appropriate services for children and young people (CYP) when needed 2. Delivering person centred care, that takes into account mental and physical health 3. Creating open door access; understanding where people can get help, support, services they need (including prevention, primary care, community, online, vcs) 4. Ensuring Mental Health is integrated into neighbourhood models of care 5. Ensuring that carers are supported as an integral part of system planning, delivery and support 6. Ensuring a joined up, confident and appropriate workforce for the STP patch including prevention, support and evidence based care for people in the communities where they live. 7. Ensuring that people with learning disabilities and autism have access to the support and services they need 8. Creating time for front line practitioners to care

Deliverables: • Improved mental health of children and young people through the delivery of the CYP transformation plan including:

• Delivery of the CYP Transformation Plan • Improved Development of local SEND partnership arrangements • Review and joint work on complex care needs for children and adults

• Improved access to services and community support for people with emotional and mental health issues by: • Developing and implementing a system all age Mental Health Strategy and embedding mental health pathways into neighbourhood models of care • Strengthening out of hours crisis response and reduce admission where possible • Increasing investment and developing an integrated model of delivery to support STP priorities (e.g. physical health, IAPT), in communities • Realigning the existing workforce to support the development of preventative models, and transformed secondary care (including social care) • Strengthening relationships and integration with community services including primary care, local authority, charities, the third and voluntary sectors • Expansion of IAPT services in partnership with primary care and physical health services • Increased access rates to IPS, IAP, EIP • Trauma informed pathways for adults and CYP

• Reduced number of suicides and attempted suicides by implementing the suicide prevention strategy and action plan • Improved outcomes for people with dementia by developing and implementing a Dementia Strategy including the delivery of newly developed dementia services.

34 |

End of Life

Priorities: • Reducing the number of people dying in acute hospital • Supporting Care Homes (competencies, skills, confidence) • Supporting out of hospital programmes to include end of life pathways, training

and support • Partnership working with all partners including hospices and the wider the

voluntary and community sector

Deliverables: Recommended Summary Plan for Emergency Care and Treatment (Respect) • Implementation of the national ReSPECT model of care led by the STP End of Life

Programme through partnership working • Workforce support through the development and implementation of an education

programme to deliver ReSPECT training and resources for the system utilising a train the trainer model including all system partners

• This will ensure a standardised and consistent process of transition and adoption of ReSPECT

• EOLC and Swan Scheme education programmes developed and delivered across system partners supported by the End of Life Care Handbook

• EOLC Volunteers trained at SaTH and Shropshire Community Health NHS Trust (looking to scale across the social care workforce)

• System-wide access to Sage and Thyme training including communication tools and techniques for all partners acute, community, hospices, council and domiciliary care.

Working with the voluntary and community sector In Shropshire and T&W voluntary, community and enterprise sector (VCSE) exists in abundance. The people of Shropshire recognise the role, importance and power of communities and the organisations that support our local areas to thrive. The role of services is to ensure that the VCSE is supported so that it can continue to thrive. When we work together, we can achieve great things. As a partnership we will continue to work with the VCSE, communities and people to support: • The development and delivery of services • Commissioning • Delivery of services in communities • Understanding of population need • Wider determinants of health

Voluntary and Community Sector

Contribution of carers The contribution ‘carers’ of all ages make to society cannot be underestimated. Locally, we acknowledge and value what carers provide day to day and the impact this has on their own lives. We believe that supporting carers is everyone’s responsibility and important in the considerations of all our strategic planning and service delivery. We must ensure: • Carers are recognised through all of services • Supported to maintain their caring role and to maintain their wellbeing • Are able to contribute to service planning and individual care as appropriate

6. System Enablement

The system workforce objectives are:

• To ensure the planning, recruitment and development of an engaged, talented and compassionate workforce for the future system

• To develop a sustainable future workforce who are equipped to meet the needs of our communities

Our STP People Strategy sets out how local organisations delivering health and social care services plan to work better together to ensure the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place to deliver quality and sustainable services to members of the public.

• The Strategy identifies four key areas for collective working; 1) Attract, Recruit and Retain; Agile Workforce, 2) Workforce Planning and Modelling, 3) Learning through Education, Development and Training Opportunities and 4) Organisational Development and Leadership including Equality and Diversity. The Strategy is underpinned by principles of system-wide, cooperation and collaboration, improvement and innovation, integration and redesign.

• As a result of achieving the ambition outlined in our People Strategy, we hope to succeed in:

• Realising the vision of the People Strategy and new models of care • Improving outcomes for service users, families and staff • Building a better understanding of system workforce • Optimising our system workforce • Supporting and enabling service improvement and redesign,

especially across boundaries

• Since the publication of the NHS Long Term Plan work continues to ensure the People Strategy reflects the ambitions and intentions outlined in the plan e.g. digital workforce and the volunteer workforce are new areas of focus that will be included within the next iteration of the People Strategy which remains a live document.

Primary Care • Significant improvement in the quality of workforce data and ability to set targets and

trajectories, & appointment of Primary Care workforce leads • Success in funding proposals for running retention programmes for GPs • Success in attracting funding for new Clinical Pharmacists • Introduction of the Physician Associate internship with four PAs to be placed in local

practices • Significant increase in engagement with GP trainees with plans for fellowships and post-

qualification support • Improved engagement with GP Nurses via established GP Nurse Educators/Facilitators and

delivery of GP Nurse 10-point action plan • Upskilling of primary care workforce in independent prescribing, spirometry, management

of long-term conditions, physical assessment and mentorship

• Mental Health • Realignment of the mental health workforce to support person-centred approach to

neighbourhood working • Training delivered across services around effective care planning/ care co-ordination • Development of system-wide mental health workforce plan which led to the establishment

of an STP Mental Health Delivery Group • HEE investment to support delivery of the mental health workforce development plan by

upskilling the workforce to achieve Five Year Forward View for mental health • Health awareness and first aid training made available across the system including health,

social care, domiciliary care, fire service, police, ambulance • Targeted recruitment for Shropshire area, focussing on selling Shropshire as a lifestyle and

good place to work • Focus on developing a new pathway for 0-25 (CYP) mental health including a workforce

model

System strategic approach to Workforce

Our Local Workforce Challenges: Fragility of workforce for acute provider across medical, nursing and therapies Recruitment challenges and high vacancy rates, related to factors such as national workforce shortages, varying terms and conditions, geographical rurality, levels of morale Cultural challenges within organisations, with some staff groups or individuals resistant to change Morale and retention of staff as a result of major change or retendering within the system An ageing workforce and a reduced community of suitable people to seek to attract An uncertain future supply of staff, with difficulty attracting students to some courses, placements and recruitment to jobs upon qualifying Different expectations of the younger workforce, e.g. increased part-time and flexible working The image of health and social care in the general population

System People Strategy

38 |

System Strategic Estates

Priorities: • Put people rather than buildings first, with population need at the heart of our estate focus • Develop ‘Place’ based integrated & co-ordinated healthcare estate, relevant to redesigned person, patient, service

user and staff delivery pathways, embedded with decisions based on a wider system view; supported by hub solutions, backed up with One Public Estate philosophy, rather than organisational self-interest

• Ensure best system use of estate assets which are relevant, accessible, efficient, safe, fit for use & purpose • Collaborate with system partners; examine & challenge organisational estate strategies and plans to identify all of

the potential opportunities for improvement and rationalisation • Support system delivery programmes leads in articulating & translating their system need into estate requirements • Ensure capital plans & asset management align with clinical strategies • Future proofing of GP services through closer working with Council planning teams to negate future planning

problems down the line • Establish a virtual STP estates team, based on supporting STP, rather than individual organisations

Deliverables: • Submit Estates Strategy Checkpoint template by June 2019 • Resubmit the STP Estate Strategy Autumn 2019 for further assessment – must be rated as ‘Good’ in order to receive

future STP estate capital • Progress project pipelines with ‘Place’ health and social care hub concept as the driver, including the acute

reconfiguration aspects associated with ‘Future Fit’ Wave 3 capital funding, co-ordinated by Sustainable Services Programme, Paul’s Moss Whitchurch health and social care hub development, and primary care at scale projects

• Produce the refresh of the Estates Chapter for the STP Long Term Plan • Improve system-wide potential disposal information, through creation of a system-wide occupancy planner, sharing

of disposals, with a disposal plan and timetable to include an understanding of associated capital investment to release assets and lead to efficiency savings

• Support efficiency programmes, estate rationalisation strategies and utilisation plans to maximise the opportunity to create a system-wide capital plan

• Support the drive to make more efficient use of space and deliver the Carter metrics, with better use of void, shared and bookable space

• Create a matrix of existing leases, marking the break clause etc. to enable system planning to take place and better manage occupancy

ESTATE AS AN ENABLER

meeting health needs for everyone

living and working in Shropshire, Telford &

Wrekin and mid Wales

Drive System Efficiency &

Effectiveness to make best use

of services

Establishing primary care

networks

Developing Neighbourhood/Locality Care

Working & Teams

Reconfigure acute hospital service sites –Wave 3 Capital

SaTH’s Sustainable

Services Programme (SSP)

Countywide community

based Muscular-

Skeletal (MSK) services

Deliver Technology

enabled care

Community Health Hubs (inc’s Mental

Health)

Supporting individual

communities to become

more resilient

Supporting people to

stay healthy

Opportunities to reduce footprint & release capital proceeds and reinvestment needs identified

Facilitating Community and Clinical Hubs

Two urgent care centres within high quality buildings Emergency Department on one SaTH site Planned Care on the other SaTH site

Better use of void, shared and bookable space; focusing on collaborations with NHS property companies, Councils, Providers, and Landlords

Joint and better use of clinical &

non-clinical space

Reviewing primary & community service locations, including community bed provision

Estate aligning with One Public Estate, including

opportunities to develop key worker housing

Improving financial transparency between ST&W STP partners’

strategic capital investment plan’s

‘People’ and ‘Place’ not ‘Building’ focused

Review maternity

services, locations,

consultant & midwife-led

care & related estate

Address, in part, the backlog maintenance

STW STP Estates Implications

Estates focusing on long-term service transformation and efficiencies

• Fit for purpose, community hubs, based on community need • Programme of opportunities, across patch, which will transform service delivery, deliver

efficiencies and enable inward investment • The proposed approach is one of prevention and wellness, building up communities,

developing resilience and reducing the future cost of care with a clear focus on housing. Reduction in packages of care costs, less stress on future finances

• Increased self sufficiency through community support and independent living – housing type is hugely important

• Long term, generational change will reduce reliance on public services

• Through creating independent living opportunities and appropriate housing to give people the lives they want

• Enabling people and organisations to integrate, work together, share problems and solutions, all in one place – collaborative working across estates function, look at shared procurement

• Allowing generational change to occur whereby people look to their own community for support, not to the public services

• Bespoke financial model for each opportunity • Funding opportunities through grants • Recycle any capital receipts through identified surplus buildings

How this can be delivered

Principles of our community centric approach • To put people at the heart of decisions • Understand the needs of the people in each area • Empowering the community to support its self • Enabling a change in community culture • Supporting people through social action • Building capacity within the voluntary sector offer space to

deliver • Targeting the specific needs of individual communities • Providing new models of ‘wrap around care’ • Developing the ‘Community Hub’ • Up-scaling and enhancing the primary care offer • Providing joined-up public services delivered at a local level • Incorporating specialist housing • Developing housing models for step down care

41 |

System Digital Enablement

Priorities:

1. Developing and delivering an Integrated care record (MCR)

2. One approach to Information Governance and data sharing for our system

3.Business Intelligence and data sharing with a focus on one system-wide view and support for population health management and prevention

4. System wide approach to infrastructure & security.

Deliverables:

• Digital sufficiently embedded as enabler in all transformation programmes • System data is available from all partners and informs integrated working and population health

management • Improved IG and data sharing • Local Digital Roadmap for 2019; focussing on: • People empowerment (“All people”) • Processes – workflow and efficiency • Pace • Digital shared care record available for appropriate use. • Initial plan to include organisations already having Electronic Patient systems, to obtain early

benefits. Other orgs to phase in later. • A standard of infrastructure across all partner sites and devices to enable digital transformation. • Early stages focussing in improving system access for mobile staff. • Mobile enabled workforce. • Progression towards Electronic Patient Record in Acute. • Electronic patient management system in UEC to replace use of paper. • Remove use of faxes across the STP area.

Next Steps: • Deliver refreshed Local Digital Roadmap for 2019. • Engage with out of hospital programmes to support and enable transformation. • Continue to engage with Maternity Services to support and enable transformation. • Create local digital infrastructure. • Define plan to deliver shared care record. • Investigate options for shared care records, including discussions with STP

neighbours • Communicate and disseminate information about system digital capabilities. • Liaise with Academic Health Science Network (AHSN) to connect with proven digital

transformation.

First GovRoam sites and devices go live

(April)

LDR agreed (May 2019)

Pilot Integrated care record specified and out for funding (Sept

2019)

GovRoam – all partners sites and

devices connect on wifi (Nov 2019)

EPR for SaTH implementation

agreed (Feb 2020)

42 |

System Communication & Engagement

Click to add text

7. Activity & Capacity Planning

System Approach to Capacity Planning

• The system is working together to understand shared capacity across collective resources

• Significant amount of work was undertaken across the system to model the capacity requirements for winter 2018/19 and this learning is being used to plan for 19/20

• Real time activity data has been used to develop this model given the significant, unpredicted growth in demand

• Further work is being undertaken to determine capacity requirements in acute and community settings

• Significant work is being done by the system to improve models of admissions avoidance, such as the ambulance conveyance reduction work. Improvement in ambulatory care models also being undertaken to minimise bed utilisation.

• The system are reviewing their assumptions and then reviewing for impact on workforce and finance to then create the plans for 2019/20

• Significant changes predicted and improvement in patient management by direction to out of hospital services will need to be profiled, in order to accurately forecast demand, e.g. 111, urgent treatment centres and Future Fit

• Use valued care in mental health; and improving for excellence to improve the emergency care of people with mental health

System Winter Planning Approach

• The Plan has been developed through robust engagement of all key system partners overseen by the A&E Delivery Group.

• In parallel, system demand and capacity modelling has been undertaken to determine predicted winter demand and required acute bed capacity to inform the bed bridge calculations.

• All Providers are asked to share their understanding of their demand and capacity over the winter months and provide an organisational winter plan which includes:

• Additionally, and phasing of escalation

• A workforce model to support 7-day working, senior decision making and escalation capacity

• 7-day working

• Christmas, New Year and Easter period

• Options for further surge capacity if required

System Capacity Planning Modelling - Based on 92% occupancy

April May June July August Sep Oct Nov Dec Jan Feb Mar

beds available (core) 642 642 642 642 642 642 642 642 642 642 642 642

Total beds available for +1 day 589 589 589 589 589 589 589 589 589 589 589 589

BEDS REQUIRED with LOS 6 days 633 625 664 645 624 637 628 688 654 654 634 676

8% to reduce occupancy to 92% 683 675 717 697 674 688 678 743 707 706 685 730

BED GAP -94 -86 -128 -108 -85 -99 -89 -154 -118 -117 -96 -141

Total Improvements 10 15 24 38 37 36 37 38 38 38 38 38

RESULTING BED GAP -84 -71 -104 -70 -48 -63 -52 -116 -80 -79 -58 -103

winter beds open all year 30 30 30 30 30 30 30 30 30 30 30 30

RSH ward 35 28 28 28 28 28 28 28 28 28

RESULTING BED GAP -54 -41 -74 -12 10 -5 6 -58 -22 -21 0 -45

care home beds 11 11 11 11 11 11 11 11 11 11 11 11

Hospital full protocol (without day

surgery or AEC) 8 8 8 8 0 0 0 8

RESULTING GAP -35 -22 -55 -1 21 6 17 -39 -11 -10 11 -26

?additional community capacity 20 20 20

PRH additonal capacity 28 28 28 28 28

rehab out of hospital 10 10 10 10 10 10 10 10 10

Potential GAP if these are accepted -15 -2 -25 9 31 16 27 -1 27 28 49 12

Improvement schemes to bridge bed gap

This Varies by month and includes schemes such as Acute medicin (Front door), frailty, Stranded Patients/Los Improvements

Additional solutions that can be in place as currently utilised as additional winter capacity

Potential solutions that currently don’t exist e.g. PRH additional capacity (from November), additional care home beds

Capacity schemes to bridge bed gap

System Capacity Planning Modelling - Based on 95% occupancy

April May June July August Sep Oct Nov Dec Jan Feb Mar

beds available (core) 642 642 642 642 642 642 642 642 642 642 642 642

Total beds available for +1 day 589 589 589 589 589 589 589 589 589 589 589 589

BEDS REQUIRED with LOS 6 days 633 625 664 645 624 637 628 688 654 654 634 676

5% to reduce occupancy to 95% 664 656 697 677 655 669 659 723 687 686 666 710


This Varies by month and includes schemes such as Acute medicin (Front door), frailty, Stranded Patients/Los Improvements

Total Improvements 10 15 24 38 37 36 37 38 38 38 38 38


winter beds open all year 30 30 30 30 30 30 30 30 30 30 30 30

RSH ward 35 28 28 28 28 28 28 28 28 28

RESULTING BED GAP -35 -22 -54 8 29 14 25 -38 -2 -1 19 -25

care home beds 11 11 11 11 11 11 11 11 11 11 11 11

Hospital full protocol (without day surgery

or AEC) 8 8 8 8 0 0 0 8

RESULTING BED GAP -16 -3 -35 19 40 25 36 -19 9 10 30 -6

?additional community capacity 20 20 20

PRH additonal capacity 28 28 28 28 28

rehab out of hospital 10 10 10 10 10 10 10 10 10

POTENTIAL POSITION if these are accepted 4 7 -5 29 50 35 46 19 47 48 68 32

Potential solutions that currently don’t exist e.g. PRH additional capacity (from November), additional care home beds

Additional solutions that can be in place as currently utilised as additional winter capacity

Capacity schemes to bridge bed gap

Improvement schemes to bridge bed gap

8. System Finances

System Financial Position

£m SCCG TWCCG SaTH RJAH SCHT TOTAL

2019/20 Control Total (12.3) 0.0 (17.4) 2.0 0.0 (27.7)

2019/20 Plan Surplus / (Deficit) (23.8) 0.0 (24.3) (0.5) 0.0 (48.6)

Variance to Control Total (11.5) 0.0 (6.9) (2.5) 0.0 (20.9)

Risk to Delivery:

Unidentified CIP/QIPP 0.0 (4.9) (7.8) 0.0 (2.0) (14.7)

High/Medium Risk Schemes (7.0) (2.0) (4.8) (3.3) (1.5) (18.6)

Transformational Change Programmes 1.1 0.9 2.5 1.3 0.2 6.0

Contingencies/Reserves/Other 1.3 2.5 0.0 0.8 (0.5) 4.1

Total Risks to Delivery (4.6) (3.5) (10.1) (1.2) (3.8) (23.2)

• Delivery of current plans require total cost-out savings of £51.6m across the system. All organisations in the system continue to review QIPP/CIP plans to maximise deliverable savings in 2019/20 and to manage internal organisational cost pressures.

• Our transformational change programme identifies a pipeline of opportunities that can deliver up to £53m over the next four years. We are

committed to accelerating the work on these programmes but this is unlikely to address in full the gap identified in 2019/20 • In recognition of the financial situation we continue to review a number of additional potential cost savings. However a number of these areas

would impact on organisational performance and the delivery of constitutional targets and would therefore require full commitment from commissioners, providers and regulators.

Note: • All figures exclude PSF, FRF and MRET • Issues referred for national resolution to

NHSI/E have been included in the plans: o Resolution of national tariff

(RJAH) - £2.5m o GP indemnity delegated budget

adjustment (SCCG) - £1.5m • Favourable resolution of these issues

would reduce the variance to Control Total

• Confirmation of national solution required from NHSI/E regarding pay award funding for LA services (SCHT) - £0.5m

1



2019/20 Financial Plan Update


Claire Skidmore- Chief Finance Officer


Laura Clare- Deputy Chief Finance Officer

Presenter:

Claire Skidmore- Chief Finance Officer

Purpose of the report: This report updates the Governing Body on the Financial Plan submission made to NHSE on 4th April 2019 and summarises the changes since the draft submission on 12th February 2019.

Key issues or points to note: The plan submitted does not currently meet the CCG 2019/20 control total of a £12.3m deficit, it instead shows a planned £23.8m deficit. This is achieved with an identified QIPP of £19.5m (4.2%) and there is significant risk highlighted within certain schemes. The plan therefore also has total unmitigated risk of £4.6m Key changes since the February submission are highlighted in the report including:

- Changes to CCG allocations

- Updates to the CCG 2019/20 QIPP plan

- Updates to figures within the categories within the Financial Plan

- A high level 5 year financial plan summary

Actions required by Governing Body Members: 1. Note the updated 2019/20 plan submitted to NHSE on 4th April 2019 and note the risks

inherent within it;

2. Note the assumptions that have been made throughout the planning process;

3. Note the additional processes in place to mitigate the risks identified in the plan;

4. Approve operation under the plan presented in this paper whilst the CCG continues to work

across the system and with its regulator to address the gap to control total currently modelled.

2



1 Additional staffing or financial resource implications Yes The report demonstrates that the CCG cannot currently operate within its financial

resource allocation





6 Risk to financial and clinical sustainability Yes The current financial plan has a £12m unidentified QIPP and therefore does not

meet the required NHSE control total for the CCG

3

NHS Shropshire CCG

Governing Body Meeting- 8th May 2019

2019/20 Financial Plan Update Executive Summary

- This report updates the Governing Body on the Financial Plan submission

made to NHSE on 4th April 2019 and summarises the changes since the draft

submission on 12th February 2019.

- The plan submitted does not meet the CCG 2019/20 control total of a £12.3m

deficit and instead shows a planned deficit of £23.8m.

- Identified QIPP is £19.5m (4.2%) and there is significant risk highlighted within

certain schemes.

- The plan therefore has total unmitigated risk of £4.6m.

- Key changes since the February submission are highlighted in the report

including:

*Changes to CCG allocations

* Updates to the CCG 2019/20 QIPP plan

* Updates to figures within the categories within the Financial Plan

* A high level 5 year financial plan summary

Actions required by Governing Body Members: 1. Note the updated 2019/20 plan submitted to NHSE on 4th April 2019 and note the

risks inherent within it;

2. Note the assumptions that have been made throughout the planning process;

3. Note the additional processes in place to mitigate the risks identified in the plan;

4. Approve operation under the plan presented in this paper whilst the CCG

continues to work across the system and with its regulator to address the gap to

control total currently modelled.

4

Updates made to the 2019/20 Financial Plan since the Plan submission on

12/02/2019

2019/20 Allocation adjustments

1. Since the plan was submitted in February, NHSE have reduced the CCG

allocation for 2019/20 by £1.4m. These changes are outlined below in Table

1:

Table 1: 2019/20 Allocation adjustments between February and April 2019

Allocation February Plan

£’000

April Plan

£’000

Change

£’000

Reason

Programme 415,563 415,448 (115) Agenda for

change pay

uplift reduction

and transfer to

specialised

services

Co

Commissioning

45,891 44,570 (1,321) Reduction for

CNST GP

Scheme

Running Cost 6,610 6,610 -

Total 468,064 466,628 (1,436)

Updated 2019/20 QIPP Plan

2. The latest QIPP plan is attached at Appendix A. The current identified QIPP

value is £19.5m and each QIPP scheme was RAG rated in accordance with

confidence in delivery of planned savings.

3. There is a commitment across the STP to identify collaborative

transformational schemes that consider the whole system financial position

with a focus on removing costs rather than moving pressures between

organisations. The STP Senior Leadership Group has identified an initial list of

programmes which is being developed into work plans with identified

executive leads for all areas. These are being shown as potential mitigation

against QIPP risk within the Shropshire CCG financial plan.

2019/20 Summary Plan Figures compared to 12th February submission

4. A summary of the proposed 2019/20 plan by category is shown in Table 2

with a comparison to the February planning submission. Changes have been

made due to budget setting discussions, QIPP development and contract

negotiations. All figures are being discussed and signed off by budget holders.

5

Table 2: 2019/20 Summary Financial Plan

Category Feb Submission

£’000

April Submission

£’000

Change

£’000

Total Allocation (468,064) (466,628) 1,436

Acute 238,942 232,244 (6,698)*

Mental Health 44,419 42,152 (2,267)*

Community 46,552 48,925 2,373

Continuing Care 34,302 35,054 752

Primary Care 60,892 62,629 1,737

Primary Care Co-

Commissioning

45,891 45,875 (16)

Other 14,762 14,601 (161)

Running Costs 6,610 6,610 0

Contingency 2,340 2,333 (7)

Total Expenditure 494,710 490,422 (4,288)

Total Planned

Deficit

26,646 23,794 (2,852)

*Note that the contract reserves previously lodged in the acute and mental

health section have now manifested across contracts in these areas as well

as in community and primary care now that contracts have been agreed.

Risk and Mitigations

5. As can be seen in Appendix A, each QIPP plan has been RAG rated in terms

of level of confidence in delivery of the savings planned. 80% of the value of

red QIPPs and 50% of amber QIPPs have been highlighted to NHSE as a

risk. When added to other small risks identified, the total risk in the financial

position is £8m. The CCG has only the 0.5% mandated contingency in place

to deal with any in year risk. STP QIPP schemes that are currently in

development have also been included as potential mitigations against risk.

After these are taken into account the CCG has a total unmitigated risk of

£4.6m to its financial position. This is shown in Table 3 below:

6

Table 3: Risks and Mitigations

Risks Mitigations Unmitigated

Risk

£’000 £’000 £’000

Red RAG

QIPPs- 80%

(5,529) 0.5% mandated

contingency

2,333

Amber RAG

QIPPs- 50%

(1,491) STP QIPP

Schemes

1,100

Prescribing

risk (NCSO)

(1,000)

TOTAL (8,020) TOTAL 3,433 (4,587)

6. In order to address the unmitigated risk a number of actions are underway,

these include:

Executive level discussions around risk assessment and mitigation

A Workshop has been arranged on 10th May to focus on further

opportunities to bridge the QIPP gap using intelligence gathered from

various sources and referencing Right Care packs produced in April

2019.

QIPP and CIP (Cost improvement Plans) are now a standing agenda

item for Strategic Commissioning Boards within SaTH, RJAH, SCHT

and MPFT.

QIPP Programme Board is exploring the robustness of project

timelines and opportunities to bring forward work.

A session is due to be held in Early May with Directors of Finance and

Deputy Directors across the system to review recent STP

Transformational Opportunities which have previously been identified.

There is also a plan for an STP QIPP group to be set up to include

Finance, Operational Managers and Clinicians.

Five Year Plan

7. The April plan submission now also includes a high level 5 year financial plan.

The submission for this is shown below. The key assumption currently made

in this plan is an ambitious QIPP target in excess of 4% a year.

7

8. An in-year 1% surplus would be achieved by Year 3 and 2% surpluses from

2022/23 would contribute to repayment of the historic debt. If the CCG

achieved this QIPP value each year it would finish the five year period with an

£82.6m cumulative deficit compared to £100.4m cumulative deficit currently

planned in 2019/20.

Conclusion

9. In summary Shropshire CCG is currently unable to submit a financial plan

which meets our control total of £12.3m. In order to do so would mean

identifying a further £11.5 million of QIPP. The CCG would then have a total

QIPP ‘ask’ for 2019/20 of £31m (6.7% of its resource limit) This is deemed to

be unrealistic.

10. There is also currently an additional level of unmitigated risk due in the main

to confidence levels in the identified QIPP schemes. This position clearly

represents a significant challenge for the CCG in 2019/20 and we continue to

work both within the CCG and across the STP to identify mitigations to reduce

this risk.

11. It is clear that we will not be able to close this gap in isolation and the work

across the STP in developing transformational change programmes will be

essential in delivering the required savings.

Recommendation 12. The Governing Body is requested to:

Note the updated 2019/20 plan submitted to NHSE on 28th March

2019 and note the risks inherent within it;

Note the assumptions that have been made throughout the planning

process;

Note the additional processes in place to mitigate the risks identified in

the plan;

Approve operation under the plan presented in this paper whilst the

CCG continues to work across the system and with its regulator to

address the gap to control total currently modelled.

Future balanced state 2018/19

£m FOT Plan Change Plan Change Plan Change Plan Change Plan Change

Programme 405,145 415,448 10,303 433,595 18,147 452,617 19,022 472,003 19,386 491,596 19,593

Running Costs 6,770 6,610 (160) 5,835 (775) 5,835 - 5,835 - 5,835 -

Delegated 43,033 44,570 1,537 46,299 1,729 48,176 1,877 50,301 2,125 52,810 2,509

In year allocation £m 454,948 466,628 11,680 485,729 19,101 506,628 20,899 528,139 21,511 550,241 22,102

Acute 226,679 232,244 5,564 231,196 (1,048) 230,523 (673) 236,027 5,504 241,896 5,869

Mental Health 39,963 42,152 2,189 42,931 779 43,679 748 44,500 821 45,268 768

Community 45,500 48,925 3,425 50,352 1,427 51,829 1,477 55,467 3,638 59,250 3,783Continuing Care 34,806 35,054 248 36,143 1,089 37,289 1,146 40,793 3,504 44,556 3,763

Primary Care incl co-commissioning 106,252 108,504 2,252 108,851 347 109,312 461 111,457 2,145 113,607 2,150

Other Programme 11,305 14,601 3,296 17,949 3,349 20,021 2,072 21,101 1,080 25,185 4,084

Running costs 7,414 6,610 (804) 5,835 (775) 5,835 - 5,835 - 5,835 -

Contingency - 2,333 2,333 2,431 98 2,535 104 2,643 108 2,753 110

Total costs 471,919 490,422 18,503 495,688 5,266 501,023 5,335 517,823 16,800 538,350 20,527

In year surplus (16,971) (23,794) (6,823) (9,959) 13,835 5,605 15,564 10,316 4,711 11,891 1,575

CSF to be awarded - -

Cumulative Surplus/(Deficit) (76,638) (100,432) (23,794) (110,391) (9,959) (104,786) 5,605 (94,470) 10,316 (82,579) 11,891

2019/20 2020/21 2021/22 2022/23 2023/24

8

Appendix A: 2019/20 QIPP plan

QIPP Scheme 2019/20 Gross Investment 2019/20 Net Savings High Confidence_ Some Confidence Low Confidence

Autism AND Asperger's Provision 20 0 20 0 0 20

COPD Scheme 656 0 656 0 656 0

Dermatology Commissioning Options 42 0 42 42 0 0

Fracture Liasion Service 115 220 -105 -105 0 0

Frailty front door 420 420 0 0 0 0

Heart Failure 374 0 374 0 374 0

HISU 120 0 120 0 120 0

Home Oxygen Assessment & Review Service 51 0 51 0 51 0

Shropshire Care Closer to Home Transformation Programme - Demonstrator Sites1,000 0 1,000 0 0 1,000

Shropshire Care Closer to Home Transformation Programme - Admission Avoidance Team2,900 1,000 1,900 0 0 1,900

Additional VBC 250 0 250 0 250 0

MSK 3,092 0 3,092 3,092 0 0

Category 1 PLCV 35 0 35 35 0 0

Ex-Tel (SaTH) 764 0 764 0 764 0

Ex-Tel (Investment) 0 133 -133 0 -133 0

CAS (Out of area mental health) 290 87 203 0 0 203

CHC AQP 329 0 329 0 0 329

Collaborative Commissioning 300 0 300 0 0 300

Joint children’s placements 500 0 500 0 0 500

Review Programme 452 0 452 0 0 452

Additional CHC 1,000 0 1,000 0 0 1,000

RJAH 852 0 852 852 0 0

SaTH 623 0 623 623 0 0



Shropshire Community Health Trust Contract (OOH Service) 757 0 757 757 0 0

Running Costs Review 350 0 350 175 0 175

Running Costs 20% 413 0 413 0 0 413

Appliances (Stoma) 40 22 18 18 0 0

Appliances (Wound) 180 0 180 180 0 0

Care home and domicillary services & polypharmacy 440 24 416 416 0 0

Diabetes 150 47 103 103 0 0

Drug Switches / Switching Programme 800 0 800 800 0 0

Prescription Ordering Direct (POD) 1,030 578 452 452 0 0

Respiratory 220 20 200 200 0 0

Secondary Care Optimisations - Biosimilars (RJAH) 431 0 431 431 0 0

Secondary Care Optimisations - Biosimilars (SaTH) 386 0 386 386 0 0

Self-Care 200 0 200 200 0 0

Prescribing Stretch Target 133 0 133 0 0 133

Co-Commissioning Efficiencies 216 0 216 0 0 216



22,088 2,550 19,538 9,565 3,062 6,911

1



Patient and Public Involvement – Getting it Right


Sam Tilley, Director of Corporate Affairs



Meredith Vivian, Lay Member, Patient & Public Involvement

Presenter:



Purpose of the report: The purpose of the report is to clarify the patient and public involvement requirements of the CCG and

recommends approaches for fulfilment of them

Key issues or points to note: Over the past 18 months Shropshire CCG has been developing and improving its approach to involving patients and public in the work it carries out. This paper sets out a summary of the legal requirements to which the CCG must adhere, a range of principles on which the CCG’s approach to Patient and Public Involvement (PPI) is based, and the ways in which the CCG will apply this in practice.

Actions required by Governing Body Members: The Governing Body is asked to support the principles and methods of practical application of those principles set out in this paper.

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6 Risk to financial and clinical sustainability No If yes, please provide details of the risk to financial and clinical sustainability

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Shropshire CCG Governing Body Meeting 8 May 2019

Patient and Public Involvement – Getting it Right

Sam Tilley - Director of Corporate Affairs

Meredith Vivian, Lay Member, Patient and Public Involvement

Introduction 1. Over the past 18 months Shropshire CCG has been developing and improving its

approach to involving patients and public in the work it carries out. This paper sets out a summary of the legal requirements to which the CCG must adhere, a range of principles on which the CCG’s approach to Patient and Public Involvement (PPI) is based, and the ways in which the CCG will apply this in practice.

Report 2. What the Law Requires

In summary Section 14Z(2) of the NHS Act 2006 stipulates that CCGs must involve patients and the public in:

Planning of services;

The development and consideration of proposals that may change the

range of services available or the manner in which services are provided;

Decisions affecting services, where those decisions will change the range and manner.

The nature of the ‘involvement’ is dependent on the issue under consideration but must be proportionate. Thus, a small adjustment to services might simply require patients being informed about the change whilst a wide-ranging change to services (a reconfiguration) might necessitate formal consultation. The patients and the public who must be involved are those that do use or may use the services under consideration. For example, changes to midwifery provision should involve recent or future parents, not the patient population at large.

3. The NHS Constitution The 7th principle of the NHS Constitution states that the NHS is: ‘Accountable to the public – through openness and transparency of decisions’ And the Constitution’s 1st value is: ‘Patients come first in everything we do. We fully involve patients, staff, families, carers, communities, and professionals inside and outside the NHS. We put the needs of patients and communities before organisational boundaries. We speak up when things go wrong.’

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4. CCG Principles. The CCG will seek to involve patient and the public based onh the following principles:

Purpose: Before seeking representation on any CCG board or committee there should first be clarity on the purpose of that involvement. For example, is it to:

Provide a single person’s objective view on the matters under discussion;

Represent the views of patients affected by the decisions about to be made;

Facilitate communication back to a wider patient population;

Demonstrate that our decision-making processes are transparent? Each of the above examples requires explicit detailing so that the board or committee understands the role of the patient representative, and just as importantly, so too does the patient representative themselves. Consistency To be sure that our approach to patient involvement is systematic across all aspects of the CCG it is important to make sure that the CCG has a consistent approach to patient representatives on boards, groups and committees.

Breadth and Diversity Wherever possible the approach to involving patients and the public should support seeking a wide range of views that are representative of different perspectives and experiences. This may mean developing multiple opportunities across a programme of work and involving a range of different people. The inclusion of a single patient representative for a programme of work is unlikely to be sufficient.

5. Getting our patient and public involvement right

There are a number of ways that we can involve patients and the public in what we do. Each method must be fit for purpose, each purpose is different. There are three roles where patient and public involvement must play a key part:

Governance and assurance

Providing the evidence base;

Informing patients of change.

5.1 Governance and Assurance The CCG appoints members of the public to sit on the Governing Body and its sub committees: Lay Members. The CCG currently has four Lay Members who provide assurance that the planning of services and the development of proposals and decisions taken are done so in the interests of the population of Shropshire and that available resources are used efficiently and effectively. In addition one of the Lay Members is specifically responsible for seeking assurance that patients and the public are appropriately involved in the work of the organisation. Thus, these arrangements are sufficient to ensure the patient view is represented in the CCG’s governance and assurance structure.

As such, Locality Committees as meetings of the GP membership, will not involve patients and the public per se but will gain assurance that the CCG is undertaking appropriate involvement via the arrangements set out above.

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Where the CCG sets up boards, committees and groups to oversee programmes of work, it is CCG policy to appoint a patient representative to sit on these. These representatives have a clearly defined role and there is existing guidance to support this involvement (attached at appendix 1).

6. Securing the patient experience evidence base

We need to ensure that patients and the public are involved in planning, development of proposals and in decisions; when they are this strengthens the evidence base for our work. There are a wide range of ways by which we can seek out and make use of the views and experiences of patients, here are a few examples:

A small group discussion at which patients are invited to talk through what the CCG is aiming to achieve in a particular piece of work and to explore ideas, experiences and suggestions;

Seeking views of patients at a healthcare setting: ‘what matters to you?’;

Asking patients to complete a questionnaire in which their preferences and ideas are sought;

Attending a specific condition group (diabetes, dementia, MS, cancer etc) to seek experiences and recommendations;

Returning to a group with a worked up idea for testing and review; Asking patients to be involved in a procurement process, i.e. working

up a specification, formulation of Invitation to Tender (ITT) documentation, being involved in the decision-making panel;

Patients Participating in review activities – did the changes improve the service?

It should be noted that if there are changes to the range of services or the manner in which those services are provided there is a requirement to involve patients in some way (the terms ‘material’ and ‘substantial’ do not appear in the legislation)

7. Informing patients

In some cases the only meaningful involvement will be one of communication of a change. In that situation it will be necessary to say what is different, the rationale for change, the process that the CCG went through and what patients need to do differently as a result.

8. A strategic approach

It is strongly recommended that at the instigation of any piece of work that will result in a change of service the following questions are posed and plans put in place:

How will we involve patients and the public in the planning of this initiative;

When and how will we involve patients and the public in the development of proposals for change;

What is the arrangement for making sure patients are involved in any decisions we need to take?

Conclusion

9. Patient and public involvement is not one thing: being clear about the purpose of the activity will inform how best to involve people in an appropriate and meaningful way. 10. Thinking about involving patients and the public at the start of any initiative will ensure that the work is done in time and that we derive the benefits of the input people make.

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Recommendations The Governing Body is asked to support the principles and methods of practical application of those principles set out in this papers


Patient Representation on Shropshire CCG boards, committees and groups.

Guidance note

1. Any board, committee or group established to support the work of the CCG should

include patient representation unless there is a clear rationale for why such

involvement would not be appropriate.

2. Members of the public should be invited to apply to participate in the board,

committee or group under consideration.

3. The opportunity to participate in any CCG board, committee or group should be

publicised through such channels as the Shropshire Patients Group, Healthwatch,

condition-specific groups and more widely. Advice can be obtained on this from the

Communication and Engagement Team.

4. The Shropshire CCG Patient Representative role specification, attached at Appendix

A, should be made available to anyone wishing to be considered to become a patient

representative.

5. Particular note should be given to section 4 of the role specification –

‘Responsibilities of Shropshire CCG to patient representatives’.

6. Those wishing to participate should be asked to provide a brief description of how

they meet the role specification.

7. Where more than one person wishes to participate the person whose skills and

abilities most closely fulfil the role specification should be invited to participate.

8. Details of the role should be set out at the time that invitations to participate are

being publicised – see Appendix B for patient representative cover sheet.

9. Further advice may be sought from the Governing Body Lay Member for Patient and

Public Involvement.

Appendix A

Role, responsibilities and required skills of patient representatives on Shropshire CCG boards, committees and groups

Patient Representative Role Specification

Shropshire Clinical Commissioning Group (CCG) understands that the views, perspective and challenge of patients and the public are fundamental to its drive towards better health and health services for the people of Shropshire. * One of the ways the public and patient voice can be heard is through patient representation on those boards, committees and groups that the CCG sets up to consider and make decisions about the health services it commissions. The role specification set out below is general in nature but serves as a guide to assist patients in understanding what is required of a patient representative, and what qualities are being sought for the role. 1. The role of a Shropshire CCG patient representative is to: 1.1 Provide assurance that the views of patients and the public have been sought and considered as the programme of work develops; 1.2 Highlight where decisions made would need to be the subject of engagement, involvement and consultation and to drive agreement about how this should be achieved; 1.3 Help to explain the “case for change” around commissioning to external partners; 1.4 Contribute to meetings own ideas and experiences and where evidenced those of a wider patient population; 1.5 Provide ‘critical friend’ challenge into the group rather than represent a particular condition or interest. 2. Responsibilities of the Shropshire CCG Patient Representative: 2.1 Ensure the Board, Committee or Group’s decisions and priorities represent the best interests of people in Shropshire; 2.2 Participate fully in meetings whether in face-to-face settings or by phone /internet conferences; 2.3 Prepare for meetings by reading and reviewing all relevant documentation; 2.4 Raise areas of unresolved concern with the Chair and-or other Board, Committee or Group members; 2.5 Identify any support, training and development requirements needed to be effective in the role; 2.6 Comply with the CCG’s ‘Commissioning in Partnership – Code of Conduct’, and respecting the confidential nature of discussions when it is made clear by the Chairs that this is a requirement. 3. Skills and experience required for the role of Patient Representative: 3.1 An understanding of NHS services and how they are commissioned; 3.2 Experience of working in a Committee setting, and ability to contribute actively to the

discussions and work of the group, including undertaking specific tasks or projects as

appropriate;

3.3 Experience of advocating for patient engagement and involvement at a strategic level;

3.4 A demonstrated commitment to improving the quality of patient outcomes and quality of

care;

3.5 A demonstrated ability to interact with multiple stakeholders;

3.6 Ability to understand and evaluate complex information;

3.7 Ability to present a non-clinical perspective and offer constructive challenge;

3.8 Ability to display sound judgement and objectivity;

3.9 Ability to communicate verbally and in writing with a variety of audiences;

3.10 Have an awareness of, and commitment to, equality and diversity;

3.11 Understand the need for confidentiality.

4. Responsibilities of Shropshire CCG to Patient Representatives:

4.1 The provision of an introduction to the work and an explanation of terms, history and

aims;

4.2 Prompt payment of all expenses incurred associated with the specific work under review; 4.3 Providing all meeting documentation in the Representative’s preferred format and sending it out in good time and no later than 48 hours prior to any meeting; 4.4 Ensuring that meetings take place at accessible times and in accessible places; 4.5 The language used in documents and at meetings is, wherever possible, plain and jargon-free; 4.6 The Chair of the meeting will ensure that the Representative always has the time and opportunity to feed in views and ideas. 5. General 5.1 In accordance with Shropshire CCG’s Constitution individuals representing the CCG or engaged with CCG activities are expected to adhere to the standards of behaviour published by the Committee on Standards in Public Life (1995) known as the ‘Nolan Principles’ These principles are set out as follows:

Selflessness Holders of public office should act solely in terms of the public interest. Integrity Holders of public office must avoid placing themselves under any obligation to people or organisations that might try inappropriately to influence them in their work. They should not act or take decisions in order to gain financial or other material benefits for themselves, their family, or their friends. They must declare and resolve any interests and relationships. Objectivity Holders of public office must act and take decisions impartially, fairly and on merit, using the best evidence and without discrimination or bias. Accountability Holders of public office are accountable to the public for their decisions and actions and must submit themselves to the scrutiny necessary to ensure this. Openness Holders of public office should act and take decisions in an open and transparent manner. Information should not be withheld from the public unless there are clear and lawful reasons for so doing. Honesty Holders of public office should be truthful.

Leadership Holders of public office should exhibit these principles in their own behaviour. They should actively promote and robustly support the principles and be willing to challenge poor behaviour wherever it occurs. 5.2. Representatives will be appointed with reference to a specific role or project and/or for the duration of a specific committee/group. Roles will be subject to periodic review as deemed appropriate by the relevant committee or group * Shropshire Clinical Commissioning Group also seeks the views and experiences of the people of Shropshire through a range of activities including, for example:

- Surveys - Public forums at which people can share their needs, preferences and suggestions - Invitations to comment on proposals via web sites, telephone, comment boxes, etc - Face to face interviews in which more detailed exploration can be achieved - Consultations – large and small - Workshops at which participants are involved in the design of the shape, nature, range of services

Appendix B

Patient Representative Cover Sheet 1. Name of board, committee or group: 2. Period for which a patient representative is being sought, e.g. one meeting, a series

of regular meetings, a standing committee, etc: 3. Frequency of meetings: 4. Chair of the board, committee or group and contact details: 5. Location of meetings: 6. Brief description of the matters upon which the board, committee or group is

focused: 7. Where can further background information be found:

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Quality Committee Terms of Reference


Dawn Clarke, Director of Nursing, Quality & Patient Experience




(Quality Committee Chair)

Presenter:


Purpose of the report: The purpose of the report is to highlight to the Governing Body amendments to the Quality Committee

Terms of Reference

Key issues or points to note: The Quality Committee Terms of reference were reviewed in January 2019 to ensure they are up to date and accurately reflect the current membership. Two changes were made. The insertion of an explicit purpose and minor changes to the core Membership. The Purpose of the committee now reads as: 2 Purpose of the Quality Committee 2.1 The Purpose of the Committee is to assure the Governing Body that commissioned services, including joint commissioned services, are being delivered safely, are clinically effective and lead to a positive patient experience. 2.2 In addition, the committee aims to ensure that quality sits at the heart of everything the Clinical Commissioning Group does.

Actions required by Governing Body Members: The Governing Body is asked to approve the changes to the Quality Committee Terms of Reference

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6 Risk to financial and clinical sustainability No If yes, please provide details of the risk to financial and clinical sustainability

1

Quality Committee

Terms of Reference

1. Introduction 1.1 The Quality Committee (the Committee) is established in accordance with Shropshire

Clinical Commissioning Group’s Constitution, as a Committee of the Governing Body. These Terms of Reference set out the purpose, membership, remit, responsibilities and reporting arrangements of the Committee and shall have effect as if incorporated into the constitution.

2. Purpose of the Quality Committee 2.1 The purpose of the Committee is to assure the Governing Body that commissioned

services, including joint-commissioned services, are being delivered safely, are clinically effective and lead to a positive patient experience.

2.2 In addition, the Committee aims to ensure that quality sits at the heart of everything the

clinical commissioning group does. 3. Core Membership

Lay Member for Public and Patient Engagement (Chair)

Secondary Care Consultant

Lay Member for Governance and Audit Director of Nursing, Quality & Patient Experience Governing Body GP

Healthwatch Chief Officer (or Deputy) 3.1 In the event of the Chair of the Committee being unable to attend all or part of the

meeting, they will nominate a replacement from within the Membership to deputise for that meeting.

3.2 Representatives in attendance. The following representatives will attend as required:

Quality Managers

CCG Lead for Public Engagement

CCG Patient Insight Officer Relevant clinical lead or project lead as necessary Representative from Public Health

4. Quorum 4.1 Four core members of the Committee must be present including at least one medical and

one nursing member for the quorum to be established. 4.2 No formal business shall be transacted where a quorum is not reached.

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5. Frequency of Meetings and Attendance 5.1 Meetings will be held every month. 5.2 Members of the Committee should make every effort to attend all meetings of the

Committee. The Secretary to the Committee will monitor attendance and will report on this annually. Attendance figures will be published in the Annual Report and Accounts.

6. Authority The Committee is authorised by the Governing Body to:

6.1 Obtain professional advice, including the appointment of external advisor and/or consultants, related to its functions as it deems fit, at the expense of the Clinical Commissioning Group. Above an agreed level this will require the approval of the Governance & Audit Committee.

6.2 The Committee shall recommend appropriate action(s) that should be taken by the

Governing Body in allowing the Committee to fulfil its terms of reference. 7. Emergency powers 7.1 Where an urgent decision needs to be made in between scheduled meetings, members

of the Committee can convene an Extra-ordinary meeting to discuss a particular issue. Quorum rules in paragraph 4 still apply.

7.2 If it is not practicable to meet in person, matters can be dealt with through telephone or

the exchange of emails. The exercise of such powers shall be through Chair’s action and will be reported and minuted at the next Committee meeting.

8. Duties The duties of the Committee can be categorised as follows: 8.1 To bring together information from a variety of sources about the quality of the care

commissioned and to critically review this for action by the CCG, or providers from whom the CCG commissions.

8.2 In doing so the Committee will support the Audit Committee and Governing Body by

providing assurance and information on quality, so as to enable those to fulfil their roles and responsibilities.

8.3 The Committee will review themes and trends identified via feedback from CCG member

practices received. 8.4 In addition, the Committee will review the key issues from each Clinical Quality Review

Meeting (CQRM) held with provider trusts, presented in the quarterly Quality reports and where necessary, escalate to the Governing Body.

8.5 The Committee will review any soft intelligence which may indicate early signs of quality

failure, implementing or recommending appropriate actions. It will also take an active role in reviewing and advising on all patient safety issues, reviewing themes and trends from Serious Incidents and learning from these.

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8.6 The Committee will review the achievement of Commissioning for Quality and Innovation

(CQUIN) schemes and the delivery of the Quality Schedules of the national contract. 8.7 The Committee will receive & review policies from the Safeguarding Teams for Children

& Adults to ensure that the CCG acts to maintain effective safeguarding services and is aligned to the Shropshire Safeguarding Boards (adults and children). This will also include reviewing the reports of relevant Serious Case Reviews and other investigations and advising the Governing Body on such reports and the implementation of any associated action plans.

8.8 The Committee will receive the notes from the Health Care Acquired Infection network

meetings and will consider and review issues in relation to Infection Prevention and Control including the Infection Prevention and Control strategy and related action plans.

8.9 The Committee will support the review of the 5 main provider Quality Accounts, and the

Chair of the committee will approve the Commissioner Statements in response to the accounts.

8.10 The Committee will review reports from the Department of Health arm’s length bodies or

regulators/inspectors (for example, the Care Quality Commission) and professional bodies with responsibility for the performance of staff or functions (for example, professional leadership bodies and accreditation bodies).

8.11 The Committee will provide a forum for the review & discussion of national and other

information regarding clinical quality & patient safety, for local interpretation and action. 8.12 The Committee will ensure robust quality reporting to the Governing Body to enable the

CCG to maintain service quality, patient safety & patient experience as fundamental priorities.

8.13 The Committee will approve arrangements for dealing with complaints and Serious

Incidents. 8.14 The Committee will approve proposals for ensuring quality and developing clinical

governance in services provided by the CCG’s providers in line with any guidance issued by NHS England.

8.15 The Committee will review Quality and Equality Impact Assessments that exceed the

threshold for review by the Director of Nursing and Quality, and will provide challenge and agreement.

8.16 Following review of the quality of services within providers, the Committee will

recommend areas requiring escalation to the Corporate Risk Register and Governing Body Assurance Framework.

9. Reporting Arrangements to the Governing Body 9.1 The Committee will report to the Governing Body on a monthly basis and the following

documents will be presented:

The minutes of each meeting of the committee shall be formally recorded and retained by the Clinical Commissioning Group. A summary report and a copy of the minutes will be provided to the Audit Committee and Governing Body.

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The Chair of the Committee shall draw to the attention of the Audit Committee or Governing Body any issues that require wider consideration and/or action.

10. Annual Review of the Committee 10.1 The Committee will undertake an annual self-assessment to:

Review that these Terms of Reference have been complied with and whether they remain fit for purpose

Determine whether its planned activities and responsibilities for the previous year have been sufficiently discharged; and

Recommend any changes and / or actions it considers necessary, in respect of the above

Report to the Governing Body the outcome of the annual review 11. Committee Servicing 11.1 The Committee shall be supported administratively by the Quality Team (or other

nominated representative). The administrator will ensure:-

Agreement of the Agenda with the Chair and collation of papers in-line with the Quality Strategy and Delivery Plan

Providing written notice of meetings to Committee members, and the papers, not less than 5 working days before the meeting

Taking the minutes and keeping a record of matters arising and issues to be carried forward

Producing a single document to track the Committee’s agreed actions and report progress to the Committee;

Producing draft minutes for approval within 5 working days of the meeting.

Terms of Reference reviewed by: Quality Committee

Review Date: January 2019

Governing Body Approval Date: March 2019

Next Review Date: January 2020

1



Report from Audit Committee 24 April 2019




Keith Timmis, Lay Member - Audit

Presenter:

Keith Timmis, Lay Member - Audit

Purpose of the report: To highlight to the Governing Body key issues arising from the 24 April 2019

Audit Committee meeting and to agree any actions that result. [Formal minutes have yet to be approved.]


1. The GBAF meets expected requirements, but the Audit Committee considers the current version needs updating and can be improved. A future Governing Body development session will be considering the risks for the GBAF and the CCG’s objectives.

2. The draft CCG annual report has been submitted to NHSE. The Committee commended the work done to date and looked forward to agreeing the final version at its May meeting.

3. The draft annual accounts have been completed and the external auditors have started their audit.

4. The Head of Internal Audit Opinion rating for the CCG in 2018/19 is “Moderate”. 5. We received IA reports on: Non-GMS payments, CAMHS procurement, Workforce Controls and

the GBAF. 6. External audit advised that the CCG Value for Money Conclusion will have an “adverse”

qualification. This is because our financial position is not “sustainable”. 7. The external auditors were positive about the CCG’s work on Future Fit and the comprehensive

reporting and early escalation of our concerns about quality issues at SaTH. 8. The Committee approved the Counter Fraud Work Plan and discussed the National Fraud

Initiative data matching exercise, the new standards for counter fraud and other national developments in this field.

Actions required by Governing Body Members:

Note the final accounts’ audit will report on 21 May 2019.

Note the Value for Money Conclusion remains “Adverse”.

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6 Risk to financial and clinical sustainability No If yes how will this be mitigated

3

NHS Shropshire CCG Audit Committee Report 24 April 2019

Keith Timmis: Lay Member - Audit Matters arising 1 A policy on non-audit work by the external auditors has been received and a

version adapted for Shropshire CCG will come to the May Committee meeting.

2 Establishment control and control of interim staff will be kept under review by the Committee for this year.

3 BCF issues remain outstanding and the Committee asked for an update at its June meeting.

Board assurance framework 4 The Committee agreed the GBAF should be redrafted to update and

rationalise what the Governing Body is focusing on and ensuring there is an effective system to manage risk.

CCG Annual Report 2018/19 5 Our draft annual report was submitted to NHSE on 18 April 2019. There has

been an extensive review of the draft by AO, Chair, Directors and Lay Members. The final submission is due on 29 May 2019.

Information Governance 6 The Information Governance Assurance Toolkit submission was submitted on

28 March 2019. The CCG passed the required thresholds and there were no fundamental issues of concern. Future work on improving records management will include ensuring arrangements for interim staff.

Annual accounts 7 Draft accounts have been completed and reviewed at a meeting of Finance

staff and the Chairs of the Finance and Audit Committees. The external auditors have started their work and they will report to the Committee on 21 May 2019. The Committee discussed a summary of the main issues in the draft accounts and the likely focus by external audit.

8 There is a contingent liability for a dispute with Betsi Cadwaladr, which may end up in arbitration and a long-standing dispute with Herefordshire CCG over a charge for a CHC patient. External audit will also pay close attention to the agreement of balances’ exercise after their comments in last year’s Annual Audit Letter. None of the items identified so far are material to the accounts (the auditors have assessed materiality as £7.5m this year).

Internal Audit 9 The Head of Internal Audit Opinion is “Moderate” this year. This is an

improvement on last year and reflects the progress in the CCG’s internal controls.

10 The non-GMS payments’ audit was rated as “Moderate”. Improvements are needed in procedure notes, keeping a full audit trail and reporting of performance against KPIs.

11 The CAMHS advisory review identified lessons learnt from this procurement exercise, not only for mental health projects, but more broadly across the CCG. The main areas were the need for more effective work and continuity of key personnel at the mobilisation stage and the speed of response once indicators showed problems with the initial stages of the new service.

12 The workforce control audit was rated as “Moderate”. The awareness and implementation of processes across the CCG needs to be improved. The

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Committee also discussed specific issues relating to interim workers and the need to keep this under review.

13 The year-end review of the GBAF gave a grade “A” assessment. External Audit 14 Grant Thornton have completed their interim audit. They concluded that there

remain issues with debtors and creditors, particularly with CHC and Shropshire Council. These will be a key focus for the audit of our accounts. This will be concluded in May.

15 We had a detailed discussion about the Value for Money Conclusion. This will receive an “Adverse” opinion because of our financial position. The external auditors were positive about the CCG’s work on Future Fit and the comprehensive reporting and early escalation of our concerns about quality issues at SaTH. In the current year the auditors are hoping to see improvements in our partnership working through the Better Care Fund and the STP.

Counter Fraud 16 We approved the Counter Fraud Work Plan for 2019/20 and the underlying

risk assessment. 17 The initial output from the National Fraud Initiative data matching exercise

has not so far revealed any significant concerns. There will be a further report to the Audit Committee once the detailed work has been completed.

18 We discussed the latest version of the Counter Fraud Standards and other national developments.

Next meeting 19 The next Audit Committee is 21 May 2019.

1



Healthwatch Shropshire: Highlights January – April 2019



Lynn Cawley, Chief Officer, Healthwatch Shropshire

Presenter:

Lynn Cawley, Chief Officer, Healthwatch Shropshire

Purpose of the report: The purpose of the report is to update the CCG Governing Body on the activities and impact of Healthwatch Shropshire in the first part of 2019

Key issues or points to note: Following a Stakeholder Meeting on 15th April 2019, the Board of Healthwatch Shropshire has approved the Forward Plan for 2019-20. The Healthwatch Shropshire team has had reduced capacity since November 2018 and this has impacted on our work. A new part-time Enter & View Officer / Independent Health Complaints Advocacy (IHCAS) Coordinator joins the team from 1st May 2019.

Actions required by Governing Body Members: The Governing Body is asked to note the contents of this report.

2




2 Health inequalities Yes/No If yes, please provide details of the effect upon health inequalities





NHS Shropshire CCG

Shropshire CCG Governing Body Meeting – 8th May 2019

Healthwatch Shropshire: Highlights January – April 2019 Lynn Cawley, Chief Officer, Healthwatch Shropshire

Executive Summary and Actions Required Introduction Gathering and understanding people’s experience of using local services is

fundamental to informing the activities of HWS.

Our Forward Plan for 2019-20 has now been approved by our Board. As well as

continuing to deliver on our statutory functions, the priorities we will focus on this year

are:

1. Mental health and well-being, e.g. 0-25 services, quality of dementia care in

care homes

2. Adult Social Care, e.g. partnership work around discharge and care at home

3. Primary Care, e.g. access, technology and shared care records, out-of-hours

4. Prevention and Social Prescribing, e.g. community resilience

3

Report

1 Intelligence received

1.1 Hot topic

January – March 2019 HWS focused on gathering feedback to inform the research

we were conducting for Healthwatch England (HWE) around Perinatal Mental Health

to understand expectations and ideals for mental health and wellbeing before, during

and after pregnancy. The focus of this work was to identify what needs are not fully

met by the current system and how these could be met. Examine which aspects of

care are important before, during and after pregnancy so the system know what to

change and what to maintain for the future. Our aim was to speak to as many people

using services as possible and the people delivering those services.

Our new Communication and Engagement Officer gathered over 60 comments from

a variety of activities including 1:1 discussions, focus groups and surveys. The data

collected was shared with HWE and is now being used by HWS to produce a report

to be shared with the LMS and STP. Due May 2019. (For more details, see 2)

March – April 2019 HWS has focused on promoting our wider engagement to gather

feedback on the NHS Long Term Plan and how this can be realized in the

Shropshire, Telford & Wrekin STP Long Term Plan.

1.2 Other intelligence

In January – March 102 comments were received, in addition to the 86 for the

Perinatal Mental Health project.

The 5 main topics covered by the feedback were:

1. Service delivery, organisation and staffing (25 positive experiences, 38

negative)

2. Quality of Staffing (25 positive experiences, 6 negative)

3. Quality of treatment (21 positive experiences, 7 negative)

4. Quality of Care (19 positive experiences, 3 negative)

5. Communication between staff and patients (7 positive experiences, 12

negative)

In terms of provider, HWS has received comments from some members of staff

regarding the services provided by a hospital Trust. We are working with these staff

4

members to share their views and concerns and have written to the Trust and

received a response. We are continuing to look into this issue.

2 Communications and engagement

Regular stands and engagement talks have continued with the support of the

volunteers while completing larger pieces of work:

January – March 2019 Late 2018 HWS were selected as one of five local

Healthwatch to contribute to national research around Maternity Mental Health. Our

Perinatal Mental Health engagement saw HWS engage with over 340 people: 76

members of the public completed our survey and an additional 26 people gave us

detailed comments, we spoke to seven people working across the maternity system

(including Health Visitors, Consultant Obstetricians, Nurse Consultant Lead), and

received 10 completed staff questionnaires. We spoke to people in a range of

settings, including libraries, Sensory Groups and meetings (e.g. for Muslim women).

In partnership with the Local Maternity System (LMS), we also used this opportunity

to raise the profile of the Maternity Voices Partnership (MVP).

HWS has continued to support the work of the LMS and MLU Review attending

Stakeholder Workshops around the model in preparation for public consultation.

March – May 2019 Early this year Healthwatch England and NHS England agreed

that the Healthwatch Network would work together across their STP areas to conduct

work around the NHS Long Term Plan.

HWS is the Coordinating Healthwatch across the Shropshire, Telford and Wrekin

STP footprint. We are working with Healthwatch Telford & Wrekin to engage with the

public on the NHS Long Term Plan to gather feedback to feed into our local STP

Long Term Plan. We have worked closely with the STP to agree a focus for

engagement locally. In order to gather as many views as possible, including the

seldom heard we are using a number of approaches, including:

Healthwatch England surveys – One more general about the NHS Long Term

Plan and one that is about long-term conditions. These can be completed on-

line at http://healthwatchshropshire.co.uk/ until 17th May. Paper copies and an

Easy Read version are also available.

Focus groups with people with Dementia and their carers

Focus groups with people with Learning Disabilities and their carers,

facilitated by Taking Part

Public events to gather views on the aims of the NHS Long Term Plan and

how they should be realized in this STP area

http://healthwatchshropshire.co.uk/

5

Publicising the piece of work, including the surveys and public events, with

support of colleagues from the HWBB and STP, and Shropshire Patient

Group.

Each local Healthwatch will produce a report but these will also be combined to

create an overarching report for the STP that will be published 21st June 2019.

Lynn Cawley (Chief Officer) attended the Healthwatch England Parliamentary

Reception in January 2019 to highlight the work of the Healthwatch Network. This led

to an invitation to meet with local MPs on 26th April. The MPs have asked to be kept

updated on our work. They were particularly interested in our relationship with

providers and commissioners locally as well as the CQC. They were also keen to

hear more about our work as the provider of the Independent Health Complaints

Advocacy Service.

3. You Said We Did

We were told that it was difficult for carers of patients in need of a familiar face, e.g.

patients with dementia, to arrange to travel with the patients on hospital patient

transport. We took these concerns to the Shropshire Clinical Commissioning Group.

They have agreed that in the new service specification, due to be put out for tender,

that patients with sensory disabilities, mental health issues or dementia can be

accompanied by somebody with whom the patient is familiar and who can provide

individual support and reassurance.

4. Enter & View

All Enter & View reports are published on our web site.

Since November 2018 the staff team have worked together to ensure our Enter &

View Visit Programme has continued. We are pleased that our new part-time Enter &

View Officer is joining the team from May 1st 2019.

We are currently completing a programme of visits to care homes across the county

registered with the CQC as providing some level of Dementia care. Some of the

homes visited are also signed up to, and assessed against the Gold Standard

Framework for End of Life Care.

Reports published January – April 2019:

Mount House & Severn View

Churchill House Nursing & Residential Home – Dementia visit

Churchmere Medical Group (Claypit Street Surgery) – GP visit

Four Rivers Nursing Home – Dementia visit

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When we have completed the work around the STP Long Term Plan we hope to

work with Healthwatch Telford & Wrekin again to agree an approach to gathering

views of people using A&E at RSH and PRH.

5 Independent Health Complaints Advocacy Service

We have seen a small reduction in the number of people contacting this service over

the last year (Total: 110). However, the number of people becoming clients has

remained consistent with an average of seven each quarter (Total: 28). We have

noted that there has been an increase in the complexity of complaints or the severity

of concerns this year. In 2018-19 we saw a marked increase in the number of people

coming to us as the result of a referral from or information provided by PALS or

Complaints Departments. After the hospitals, the largest number of callers are

complaining about their GP. The top five topics of complaint are:

1. Quality of treatment

2. Staff attitude

3. Safety of care and treatment

4. Diagnostics

5. Access to a service

6 Governance

We currently have nine Board members having appointed a new Board member at

our Board meeting in public in February. Dee Walker joins us with 43 years

experience in the NHS and quality sector as a General Manager specialising in

information governance and records management.

7 Get in Touch

Please contact Healthwatch Shropshire if you would like more information about the

content of this report or to share your views and experiences of local health and

social care services in Shropshire.

01743 237884

[email protected] www.healthwatchshropshire.co.uk

Healthwatch Shropshire 4 The Creative Quarter, Shrewsbury Business Park, Shrewsbury, Shropshire, SY2 6LG

7

Summary and Conclusion

The work of Healthwatch around the NHS Long Term Plan feeding into the local STP

Long Term Plan is the first time the whole network has been tasked with completing

a project on this scale. HWE has commended our approach and we look forward to

seeing our findings incorporated into the Shropshire, Telford & Wrekin STP plan.

Recommendations

The Governing Body is asked to note the contents of this report.

1


Shropshire CCG Governing Body meeting: 8th May 2019

Committee Meeting Summary Sheet

Name of Committee:

Clinical Commissioning Committee

Date of Meeting:

February 20th 2019

Chair:

Sarah Porter Lay Member


Care Closer to Home

Memorandum of Understanding between Local Authority and Community Trust

signed

Pilot Implementation Group up and running

Demonstrator Sites agreed

Urgent Treatment Centres

Specification for service agreed

Procurement route to be discussed and agreed by Governing Body

Individual Placement Scheme

Bid for 2 years funding successful

Opportunity to secure jointly with Telford and Wrekin additional funding

VBC Policy

Agreed to incorporate further amendments to final policy

Cancer Services Strategy

Strategy being refreshed and final strategy to be presented in May with Work plan


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Procurement Route for Urgent Treatment Centres

MINUTES OF SHROPSHIRE CLINICAL COMMISSIONING COMMITTEE (CCC) MEETING HELD

IN ROOM 2, OAK LODGE AT 9.00AM ON WEDNESDAY 20 FEBRUARY 2019

Present: Mrs Sarah Porter (Chair) Lay Member for Transformation Mr Meredith Vivian Lay Member for Patient & Public Involvement Dr Julie Davies Director of Performance & Delivery Dr Julian Povey CCG Chair Dr Simon Freeman Accountable Officer Dr John Pepper GP Board Member Dr Deborah Shepherd Shrewsbury & Atcham Locality Chair Mrs Gail Fortes-Mayer Director of Contracting & Planning Mr William Hutton Lay Member Mr Kevin Morris GP Practice Manager Board Representative Dr Steve James GP Board Member Mrs Nicky Wilde Director of Primary Care Dr Matthew Bird South Locality Chair Dr Alan Leaman Secondary Care Consultant Dr Michael Matthee North Joint Locality Chair Dr Priya George GP Board Member Mr Tony Uttley Interim Deputy Chief Finance Officer Prof. Rod Thomson Director of Public Health Observer: James Lindsay In Attendance: Ms Lisa Wicks/ Mr Barrie Reis Seymour (Agenda item 19/2/015 – Shropshire Care Closer to Home) Ms Emma Pyrah (Agenda item 19/2/017 – UTC Procurement Business Centre) Mr David Whiting (Agenda item 19/2/018 – VBC Policy - draft) Apologies: Mrs Claire Skidmore Chief Finance Officer, Deputy Accountable Officer Dr Finola Lynch GP Board Member Ms Dawn Clarke Director of Nursing & Quality Dr Jessica Sokolov Medical Director Dr Katy Lewis North Locality Chair CCC-19/2/012 Apologies 1.0 Apologies were noted as above. CCC-19/2/013 Members’ Declarations of Interest 2.0 Mrs Porter requested that attendees declared any potential conflicts of interest regarding the

Committee Agenda. There were no declarations of Interest made.

CCC-19/2/014 Minutes/Actions of Previous Meeting 16.01.19 & Matters Arising 3.0 The minutes of the previous meeting were discussed and it was agreed that the following

amendments were required: CCC-19/005 Cancer transformation programme, paragraph 5.0 – Dr Shepherd advised that prostate had been misspelt and needed to be amended.

3.1 Discussions were held with regard to the lateness of circulation of some agenda items and concerns were raised that members had not had time to read the papers prior to the meeting. It was agreed that the following agenda items would be discussed at the next Executive meeting to determine whether an extraordinary CCC meeting needed to be scheduled.

IAPT

Locally Commissioned Services (LCS)

Community Equipment Service Specification 3.2 The CCC Action Tracker was discussed and updated as appropriate.

Matters Arising CCC Working Group Update – Dr Davies advised of key areas discussed:-

Respect – It had been agreed that Mrs Fortes-Mayer would be the Executive Lead for this piece of work and was being worked on through the working group and would be brought back to CCC for decision.

Community Physiotherapy Specification – currently working through more provider feedback that had been received which will be added to the specification before coming back to CCC for final decision.

Adult contact lens – advised that needed to be provided by an acute provider and that there were some contractual issues but was hopeful that they would be resolved within the next month to enable it to be brought back to CCC for decision.

Physical Health Checks – update to be brought back to CCC in March

GP Counselling Services – risk mitigations – communication and extra briefing had been worked up and had now been sent to Practices.

Update 0-25 service – It has been agreed that updates would now be brought through CCC as the risk had now reduced so did not need to go to Governing Body.

3.3 Concerns were raised around the lack of explanation and communication to Practices with regard to the de-commissioning of GP Counselling Services. Mr Vivien said that there was always a need to be respectful to people on the receiving end of any decisions and he felt that this exercise had not been communicated in a clear way, i.e. rationale to explain what was happening and when and to outline what would happen and as a result needed to ensure that this would be the lesson that was learnt going forward. Dr Davies agreed that a ‘lessons learnt’ exercise needed to be carried out and a paper brought back to CCC and to each of the Localities outlining lessons learnt and to show proposals on how things would be carried out differently in the future.

Magseed

3.4 Dr Davies advised that Dr Sokolov had been in contact with the Royal Marsden as she had been requested to seek further information from one of the centres currently using Magseed, to obtain a better understanding of any benefits or risks associated with the use of Magseed and had produced an update which was presented to members.

3.5 Dr Davies advised that there were currently capacity and flow issues within the Trust and the

use of Magseed was helping with this and said that if the CCG did not support the decision it would have an impact on patient care and patients would be delayed. Dr Shepherd said that she felt that SaTH should be covering this within the current tariff and if it was helping to improve their flow and patient experience then the Magseed should be inserted at the original assessment appointment and this would then not be at an additional cost.

3.6 Following discussions it was agreed that this update and previous papers should be taken

through the Executive Team meeting for decision going forward. Action: All previous Magseed papers to be taken through Executive Team for decision

going forward CCC-19/2/015 Shropshire Care Closer to Home 4.0 Ms Wicks and Mr Barrie Reis-Seymour presented the monthly progress update on all phases

of the Shropshire Care Closer to Home programme. Phase 1 – Frailty Intervention Team Phase 2 – Case Management Phase 3 – Acute service in the Community.

4.1 Ms Wicks informed members that the Memorandum of Understanding had now been signed between the Local Authority and the Community Trust and advised that the pilot implementation group was now up and running. She outlined issues with regard to the demonstrator sites and highlighted to members that seven practices had expressed an interest to run the demonstrator sites and that they had gone through a process within the pilot implementation group around location practice size having to match with the controlled site. The group felt that it was important to have one site going live with the new model and one site undertaking service as normal so that they would be able to map the benefits and show that the pilot sites had delivered the anticipated benefits. The report had been taken through

the secondary care data around admissions for those practices and one of the concerns raised was that the numbers were very small. From work that had been previously carried out it had been identified that to be able to achieve the admission avoidance required that they would need to be case managing in the 100s. Ms Wicks asked the group for decision as to whether to accept all pilot sites to be able to prove to the system that it worked or whether to go and target larger practices for the demonstrator sites.

4.2 Dr Leaman expressed concerns over the small number of admission avoidances that this programme would deliver. Dr James said that looking as it stands that this may be bad for CCGs reputation as there would not be the numbers there to prove and show what was wanted and suggested that there was two options for taking this forward.

Look to offer incentive to bigger practices to join the programme

Go out to procure programme to all demonstrator sites

4.3 Following discussions with regard to case management from the Practices that had expressed an interest, it was discussed whether a controlled site could be used and compare this with the current practice. Ms Wicks advised that pilot criteria had been developed but to enable data to be collected from the practices they had to agree to be part of the programme and share their data. They could go back to Practices to see if could use as controlled site to those that didn’t necessarily want to be a demonstrator. Dr Pepper thought that, if only the demonstrator sites that had been proposed in the paper were used, the study would struggle to show any significant reduction in numbers of admissions as it was likely there would be insufficient numbers of cases managed to provide that evidence. However, the demonstrator sites would nevertheless provide the opportunity to show if the model itself worked.

4.4 Dr Leaman commented that he thought admission avoidance was the main purpose of the programme and finances were based on money saved from avoidance admission and the need to reduce a significant number of admissions and asked when SaTH would notice a significant reduction number in admissions as a result of this programme. Ms Wicks advised that part of the purpose of the demonstrator sites which had been discussed with SaTH at the contract negotiation meetings was around the case management element and this is why concern has been raised with regard to the small numbers of interested practices i.e. as if have two small practices then could demonstrate that the model worked but would not show the true potential of the admission avoidance. Evidence shows that the model works but only case management would determine the activity that is required for the Hospital at Home service and again expressed this is why the numbers were important and if were not monitoring the correct patients within the pyramid then would not be able to determine the numbers that would be required for the next phase of the programme.

4.5 Dr James stated that everyone was losing sight of why the CCG was carrying out the

programme and this was about transforming care and improving patient care and keeping patients out of hospital. Evidence shows that this will keep people out of hospital, as audits that had been carried out by clinicians across both primary and secondary care looking at the admission going into both hospitals recently showed that in PRH just over 50% could be avoided and in RSH just under 50%. He outlined that only some of those would be hit by this model and others would be hit by other services, transformation and processes but said that this part was about giving a better service for practices.

4.6 Dr Freeman stated that it is not the issue whether this would work as it was clear that it did

work but needed to motivate people to want to do it as this was what would work in terms of achieving either admission or non-admission.

4.7 Dr Shepherd said that if looked at the seven practices that had expressed an interest and

were keen to commence then this would give an eligible population of around approx. 16,000 patients in the cohort of over 65s and would be big enough to demonstrate some kind of admission avoidance so suggested to nominate all seven of those practices as demonstrator sites as other practices had not expressed an interest. It was noted that the challenge could be the reluctance of Shropcom to manage those numbers.

4.8 Mr Vivien commented that needed to be careful of success criteria as it had already been

decided that this will be carried out and that this was more about establishing how to do it to the best affect not whether to do it and needed to make sure what was set up was designed to deliver what it was trying to deliver and understanding how to make cultural changes for service providers and users of both services. If going for much wider base then need to build in the capacity to measure what is happening and to learn and communicate from it.

4.9 Ms Wicks said that she was happy to proceed with the seven interested sites but her only

concern would be the timeframe for evaluation, as if showed that admission avoidance was the same between the controlled and demonstrator sites then the question would be raised as to what the controlled site was doing differently against what the programme would be capturing within the model.

4.10 Dr Davies asked Committee members to confirm that they agreed that the model should use

all seven practices that had come forward as demonstrator sites to demonstrate the impact and then hold conversations to identify how to start to work this up to scale. This would then need to be followed up with the larger practices and then would require Committee approval. It was noted that because of what was learnt from the project in Bishops Castle a specification would be included within the contract for next year for the pilot sites and the information requirements would be built into the information schedule within the contract so could evaluation what was being carried out.

4.11 Dr James advised that there was a need for someone to be carrying out data analytics before

starting the programme and was important to show that this was working. Ms Wicks advised that the resources for an information officer and a service improvement post for both phases was being discussed through the governance of the programme and said if the Committee was comfortable with this then she would take it back through the governance committee of the programme board. Dr Leaman expressed further concerns as to whether this would achieve admission avoidance. Ms Wicks agreed to meet and discuss with Dr Leaman outside of the meeting to bring him up-to-date with the programme progress so far around admission avoidance.

Members noted the progress of the programme and the next steps identified and

agreed that all 7 practices would be used as demonstrator sites

Action: Ms Wicks to meet with Dr Leaman and share progress todate around admission avoidance.

CCC-19/2/016 IAPT 5.0 As agreed under matters arising it was agreed to defer this item and take through Exec Team

for decision on taking it forward. CCC-19/2/017 UTC Procurement Business Case 6.0 Ms Pyrah presented the detailed business case to the Committee and asked for approval for

the procurement of the nationally mandated Urgent Treatment Centre for the new contract start date of 1 October 2019 prior to submission to the Governing Body for approval in March. Ms Pyrah explained that with the caveat that the CCG was exploring alternative procurement option which would mean going out jointly with SaTH rather than it being an open tender.

6.1 Dr Freeman gave a brief background and advised that the legal advice that the CCG had

received was that because there was an active market in UTC providers, they would have to formally procure a service. Dr Freeman had challenged this view as he did not feel that there was an active market in UTC providers, only an active market in providers what call Urgent Care Centres which were largely in Acute hospitals. He explained that the procurement was for around 100 patients a day average and expressed a view that this raised the question as to whether there was any other organisation other than the Acute Trust that could demonstrate that they could manage this volume of patients or secure the workforce. This meant in terms of procurement that there was the challenge of yes the CCG had to procure it but whether there was a viable procurement that did not involve the Trust and explained that this was why was now exploring the option as whether a form of managed competitive dialogue or co-tendering with SaTH could be found that would enable this issue to be addressed or asked the Committee whether they believed that the CCG should go for straight procurement and SaTH tender for it.

6.2 Dr James said that he thought key elements of this was with the consistent streaming element

being carried out by Primary Care clinicians and said that he could not see SaTH employing Primary Care Clinicians in this setting. Dr Pepper asked the Committee at what point would they be happy and should have a measure of safety, Quality and efficiency that should come out in the procurement process. Dr Shepherd felt that it might be best if SaTH went through the procurement system but acknowledged that it also made sense for the local emergency department to be aligned and integrated with this but highlighted that there was evidence that A&E performance was poor which led to the question if maybe things would be better if they didn’t win it. Dr Leaman said that he felt would make things worse at A&E at SaTH by open procurement as by taking out large number of patients currently seen in A&E departments you will reduce funding, undermine staffing and morale when morale is already at rock bottom, so felt there was a need to be very careful as to not add to current problems.

6.3 Mr Vivien felt that there needed to be a system in place and should follow rules as a starting

point. Dr Povey advised that bottom line was had to do what was legally correct and could not say that SaTH was preferred provider. Dr Davies advised that there was evidence that it had been carried out elsewhere with a competitive dialogue with their acute provider and informed had received advice from NHS England.

6.4 Ms Pyrah asked if she had the Committees support for the specification. Members agreed.

Action : It was agreed that Ms Pyrah would meet with people who had managed a similar competitive dialogue process for their equivalent UTC for a County hospital and then use this and along with legal advice to inform and bring paper to confidential section of the March Board to ask the Governing Body to make decision on the procurement route for this project.

CCC-19/2/018 VBC Policy (Draft) 7.0 Mr Whiting presented the current draft of the VBC policy and explained that there were still

some comments that have received back from the RJ&AH that needed to be taken into account. Mr Whiting asked members to accept the current version of Policy noting that there may be some changes required to the final version subject to feedback from clinical colleagues and to identify a date when policy should be completed.

7.1 Dr Davies advised that the policy had to be ready to give to providers as they have to give 30

days’ notice if want to be in place by 1 April so had to have signed off and agreed by 1 March if this did not happen would lose a month’s impact on next year’s contract.

7.2. Dr Freeman made a suggestion that the Committee approved the policy and if there were any

subsequent changes then they would be dealt with by an amendment to the policy in due course.

7.3 Dr Shepherd advised that specific clinical sections to which she had queries and questions on

where with regard to wording on following points. 8.4 Breast augmentation 6.4 Mirena Coils – agree should be criteria around fitting of coils 5.2 Epidural Injections (Mr Whiting to check guidance re. <12 weeks) 7.4 Dr Povey said that needed to ensure that the financial impacts of new policies or changes to

the policies that would be in terms of the contract had been checked and also raised that the policy needed to be communicated as changes were being made to some of the thresholds and criteria and asked what the plans where in terms of patient consultation or engagement around the changes. Mr Whiting informed that the financial analysis had been carried out. Dr Davies said that this had not yet been put onto the website. Mr Vivien asked if any of the changes would make a difference to the range of service that patients received and if there was a change then there would be a requirement to do something with patient input and needed to at least inform people that something was happening.

7.5 Mr Whiting also said that in the past it had been difficult to obtain clinical expertise to review

codes used in reporting and asked if there was expertise available amongst the CCG clinical team – it was agreed this should be carried out via the working group.

It was agreed that once comments had been checked/incorporated then the policy could be approved with the agreement that any further changes would be made via amendment to the policy.

CCC-19/2/019 Individual Placement Schemes 8.0 Mrs Fortes-Mayer presented her paper and advised the Committee that this was to update on

the development and delivery of the Individual Placement and Support (IPS) model of employment services for people accessing secondary mental health services.

8.1 Mrs Fortes-Mayer advised that had been successful in a bid which was for 2 years and now

had opportunity with colleagues in Telford to secure a wave 2 bid for additional funding to co-ordinate high-quality IPS employment services across the Shropshire and Telford and Wrekin STP footprint. Provider is in-house and been rated as a high performing service at national level. She updated that all posts were now in place for full part of the expanded service and that there is no longer a waiting list. The data set was now being shared with MPFT but explained as there had been a delay at the start in the recruitment said it was possible that might not meet the 300 contacts that were identified for the first year but that the target was accumulative so anticipated would catch up in year 2 of the service being rolled out. Highlighted that there had been 192 contacts of which 50 new job starts had occurred which was a good delivery from expanded service.

8.2 Mrs Porter asked from the 50 new jobs did we know how long each individual stayed. Mrs

Fortes-Mayer explained that the spreadsheet attached outlined numbers and said there was a need to understand what the cause was for people who did not continue and identify what was happening to them after. Mrs Fortes-Mayer agreed to take this back to the team.

8.3. Mrs Fortes-Mayer informed that part of the development was to identify sustainability of the

service in which Shropshire Council with the CCG’s support had identified mental health employment partnerships and she explained that this was a not for profits enterprise that had bid for life chances fund as part of the bigger contingent for the life chance fund. The CCG and the Council have committed to working with this organisation for two years and developed this on an outcomes basis and felt that Shropshire was currently ahead of the game and now looking to open this out so that there was a wider offer across the County.

8.4 Dr Shepherd said that when this had been presented previously concern had been expressed

over the sustainability and the CCG not being able to commit to funding and asked if the new association would eliminate any of those concerns. Mrs Fortes-Mayer said that in the two years that they had life chance fund then yes would eliminate concerns but as part of the longer term plan hoped would be here to stay and see expanded as part of the mental health ask.

CCC-19/2/020 Cancer Services Strategy 9.0 Mrs Fortes-Mayer informed members that the Strategy had not been able to address each

theme at each level and advised that they were currently refreshing the Strategy taking into account the national asks of the long term plan and best practice guidance for cancer, some of the delivery issues being experienced in Shropshire Telford and Wrekin but also would include the next steps and identifying where to be placing ourselves with regard to networking for tertiary services/diagnostic networks.

9.1 Strategy should be completed by May and once completed would be brought back to the CCC

along with the work plan. 9.2 Mrs Fortes-Mayer advised that there was a need to find new Clinical Chair for the Cancer

Strategy Group as Dr Inglis was retiring. Dr Sokolov was currently looking for suitable alternative across the STP. Members were asked if anybody had suggestions to please let Dr Sokolov know.

ACTION: Completed Strategy to be brought back to CCC along with the work plan – Any ideas re. new Clinical Chair for the Cancer Strategy Group to be fed back to Dr Sokolov.

CCC-19/2/021 Any Other Business There were no items of any other business raised.

Date of Next Meeting The next meeting of the Clinical Commissioning Committee will be held on Wednesday 20 March 2019 at 9.00am in Meeting Room B, William Farr House.

1


Shropshire CCG Governing Body meeting: 8th May 2019


Name of Committee:

Clinical Commissioning Committee

Date of Meeting:

20th March 2019

Chair:

Sarah Porter Lay Member


Care Closer to Home

Business case for Demonstrator sites discussed and agreed

Admission Avoidance

Business case for an admission avoidance plan discussed. Revisions agreed.

Community Equipment Services

Proposed service specification presented. KPIs discussed and agreed to ensure

assurance

IAPT

Additional invested discussed and supported to enable immediate recruitment

Primary Care Strategy

Circulated for information

Fracture Liaison Service

Support for this service to proceed to next steps

Flash Glucose Monitoring

Policy approved

VBC

2

Agreed to consider aligning to a single policy with Telford and Wrekin


MINUTES OF SHROPSHIRE CLINICAL COMMISSIONING COMMITTEE (CCC) MEETING HELD

IN ROOM 2, OAK LODGE AT 9.00AM ON WEDNESDAY 20 MARCH 2019

Present: Mrs Sarah Porter (Chair) Lay Member for Transformation Dr Julie Davies Director of Performance & Delivery Mrs Claire Skidmore Chief Finance Officer, Deputy Accountable Officer Dr John Pepper GP Board Member Dr Deborah Shepherd Shrewsbury & Atcham Locality Chair Mr Kevin Morris GP Practice Manager Board Representative Mrs Nicky Wilde Director of Primary Care Dr Matthew Bird South Locality Chair Dr Finola Lynch GP Board Member Dr Jessica Sokolov Medical Director Dr Katy Lewis North Locality Chair Dr Alan Leaman Secondary Care Consultant Prof. Rod Thomson Director of Public Health Ms Samantha Bunyan Head of Quality and Safety Dr Steve James GP Board Member Mrs T Attfield Personal Assistant (Minute taker) In Attendance: Ms Lisa Wicks (Agenda item 19/3/025 – Shropshire Care Closer to Home) Ms Alison Massey (Agenda item 19/3/029 – Fracture Liaison Service Business Case) Miss Clare Michell-Harding (Agenda item 19/3/030 – Flash Glucose Monitoring) Ms Michele Rowland-Jones (Agenda item 19/3/031 – Sacubitril Valsartan Induction Commissioning Policy) Apologies: Mr Meredith Vivian Lay Member for Patient & Public Involvement Dr Simon Freeman Accountable Officer Dr Julian Povey CCG Chair Mrs Gail Fortes-Mayer Director of Contracting & Planning Mr William Hutton Lay Member Ms Dawn Clarke Director of Nursing & Quality CCC-19/3/022 Apologies 1.0 Apologies were noted as above. CCC-19/3/023 Members’ Declarations of Interest 2.0 Mrs Porter requested that attendees declared any potential conflicts of interest regarding the

Committee Agenda. The following declarations of Interest were made.

Dr John Pepper – GP/Partner/member of Darwin/Employer of practice counsellor Mr Kevin Morris – Partner Cambrian Medical Centre/wife works for Telford & Wrekin CCG Dr Matthew Bird – GP Partner Albrighton Medical Practice/GP Appraiser/Member of Shropdoc Dr Alan Leaman – Consultant previously employed by SaTH Dr Finola Lynch – GP Bishops Castle/husband works for Shropdoc Dr Jessica Sokolov – Father on Board of Governors for WMAS and is a County Councillor Dr Katy Lewis – GP Principal, Westbury Medical Practice Prof. Rod Thomson – Local Authority employee

CCC-19/3/024 Minutes/Actions of Previous Meeting 20.02.19 & Matters Arising 3.0 The minutes of the previous meeting were discussed and it was agreed that the following

amendments were required: CCC-19/2/015 Shropshire Care Closer to Home – Dr Pepper advised that the wording under 4.3 did not reflect the conversation held and the last sentence should have read……

"Dr Pepper thought that, if only the demonstrator sites that had been proposed in the paper were used, the study would struggle to show any significant reduction in numbers of admissions as it is likely there would be insufficient numbers of cases managed to provide that evidence. However, the demonstrator sites would nevertheless provide the opportunity to show if the model itself worked".

3.1 The CCC Action Tracker was discussed and updated as appropriate.

Matters Arising CCC Working Group Update – Dr Davies advised that a number of specifications had been presented to the Working Group meeting and informed that the challenges identified were with regard to Providers accepting the specifications. SaTH – The COPD specification had been worked up with Shropcom and the CCG was now looking to obtain agreement but advised that this had not been forthcoming and this would have a significant impact on QIPP scheme for next year. This had been escalated to Mr Steve Gregory, Director of Nursing who had assured that he would provide issues/concerns to Dr Davies by lunch-time Friday 22 March. Pain Solutions Specifications – Dr Davies advised that the revised specification would hopefully be ready to be presented to April or May CCC.

CCC-19/3/025 Shropshire Care Closer to Home 4.0 The monthly Shropshire Care Closer to Home update was presented for information.

Papers were presented on both business cases for the Demonstrator Sites and Admission Avoidance.

Demonstrator Sites

4.1 Ms Wicks informed members that she was seeking approval of the proposed QIPP business case and explained that this would underpin the current Shropshire Care Closer to Home Transformation Programme and outlined benefits from the SaTH contract in terms of admission avoidance. Once agreed, this would form a contract variation in the 19/20 contract with SaTH. The demonstrator sites had clear criteria using Secondary Uses Service (SUS) data and would be targeting intelligence from General Practice and Social Care data and she anticipated that the teams would be case managing approximately1500 patients.

4.3 Mr Morris asked what the impact would be on Community Services. Ms Wicks advised that

she had met with Community Trust to identify how they would mobilise their teams to deliver the demonstrator sites and one of their solutions had been to join IDTs and ICS together which would mean one phone call to the locality and that they had offered some proposed activity and that she was currently carrying out an impact assessment within the impact assessment group.

4.4 Dr Lynch highlighted that at least one other practice had said that they would be happy to be a

comparator and asked if any other practices had come forward or whether there was a need to portray a message back out to Localities that the CCG were still looking for Practices to be comparators. Ms Wicks advised that a dedicated communications and communications lead had now been appointed and was commencing this week and one of her first tasks would be go out to Practices to identify sites.

4.5 Dr Lynch suggested the need to include community care co-ordinators within the section

under low level need within the paper. She also informed that GPs had asked about the interdependency between the team and social care so it needed to be clear which health led professionals were involved in the hub, and explained that one of the key elements of the work was to access social care quickly so there was a need to be clear how they interlink. Ms Wicks advised that the wrap around team and the Local Authority is part of the memorandum of understanding and explained that the team was not a health team but an integrated team and said agreed to bring the workforce work back to members as this would clarify and make clear who the core team would be around the pilot sites. Members agreed that this would be helpful to enable a clear understanding.

4.7 Ms Porter presented to members a question raised by Mr Vivien who had said that there were

key roles required to ensure delivery of the fundamental transformation programme and that the programme board had asked how the roles would be resourced but to date nothing had been resolved and he asked if the CCC could make a clear decision on the next steps. Ms Wicks informed that she had been tasked at the last Programme Board to complete a business case showing where the CCG was now and what resources were required and she had completed a full business case and shared with Dr Davies and Dr Sokolov and this would now be presented to an extraordinary Programme Board to discuss this and how to mobilise the pilot implementation.

ACTION: Ms Wicks to bring paper outlining workforce detail to enable clarity

Admission Avoidance 4.8 Dr Sokolov advised members that the presented business case was not phase 3 of care

closer of home and that it was in response to system pressures with regard to admission avoidances, internal SaTH processes and discharge processes and that the three segments helped manage the flow and pressures through the system. She explained that SaTH’s internal processes purely belonged to them and the CCG would push and support them and that the supported discharges worked really well so this only left the front door segment around admission avoidance and stated that there was an urgent need to ensure that was in a better place for next Winter and even though the whole scheme of closer to home was around looking at admission avoidance, this would not be completed in time for next Winter so explained that the business case was an interim rescue measure and expectation was that by the time Phase 3 was completed this will be incorporated into it and staff Tuped across. She summarised that the concept was what could be done quickly to have greatest impact and said that this would be to put a very high banded autonomous high functioning team in to carry out the hospital at home and rapid response elements in the largest population centre, i.e. Shrewsbury and advised that the final overall system would be countywide. Dr Davies advised that the concept had been shared with the system leaders group as part of the STP to achieve the highest possible support and acknowledgement that the system required action before next winter.

4.9 Members suggested that there was a need to rewrite the front page of the report presented to

ensure that it was clear why the Business Case was required as it was felt that this did not portray the correct message.

4.10 Dr Lynch expressed concerns over data differences as the current paper referenced a

different number in relation to admission avoidance beds against the previous phase two paper. Ms Wicks advised that SUS data had now been refreshed. Dr Lynch said that needed to be clear that it was not referencing future fit data now and outline new number to keep messaging consistent as would receive challenges with regard to timeline around phase 3.

4.11 Dr Shepherd expressed concerns that paper was not very clear as to why it was different to

Shropshire Care Closer to Home and did not want this to be interpreted incorrectly so advised that needed to think how going to address this and offer reassurance. Dr Sokolov agreed that would have challenges but advised that there was no way to mitigate this and would ensure that clear engagement and communication would be key.

4.12 Discussions were held and concerns expressed around phase 3. Dr Sokolov summarised

that the business case that members were being asked to approve was not around county wide multi-faceted phase 3 work but was purely a high impact team going into one area to alleviate pressures for next Winter, and explained that whilst the business case had elements of phase 3 in it she reiterated that it was important to hold this separately when making decision on presented business case. It was agreed that before members were happy to approve the proposed business case it needed to be re-written for clarity. Members agreed that they could agree with the principal but the revised paper outlining rationale would need to be presented under chairs action to Mrs Porter, Dr Shepherd, Dr Bird and Dr Lewis. Ms Wicks agreed that a name change was required to ensure clarity i.e. rapid response/intermediate care for winter pressures in Shrewsbury.

Action: Revised paper to be submitted under Chair’s action to Ms Porter/Dr Lewis/Dr Bird and Dr Shepherd before the next meeting to approve before distribution. Ms Wicks to meet Dr Leaman to address concerns before next meeting Members approved the business case for the Demonstrator Sites.

CCC-19/3/026 Community Equipment Services 5.0 Ms Wicks presented a proposed service specification jointly agreed with Telford & Wrekin

CCC for approval and explained that this would underpin the current Community Equipment Service provided by the Community Trust. Ms Wicks informed that the agreement was for standard equipment only and made the committee aware that once the standard equipment service specification was in place there would then be a need for a complex equipment service specification. Dr Davies advised that the specification had been taken through the Executive Team and highlighted three areas that were raised.

Need to ensure financial envelope – advised that this was within Shropcom’s budget

Only commission what is statutory – clarified that seating had been removed

Cover CHC equipment –confirmed that this was included within specification

5.1 Dr Leaman said that he felt that the service should be running 7 days per week. Dr Bird

highlighted that there was an overlap with the ICS team and that the specification was more around a planned need. Mrs Skidmore highlighted that there would be a funding implication to this being a 7 day service. Dr Leaman asked if the voluntary service i.e. red cross was being fully utilised as they could help in providing equipment and would help in providing a quicker response. Dr Davies agreed to look at options of a 7 day service and explore working with the voluntary sector and obtain financial implications.

5.2 Dr Lewis stated that the specification outlined that they would deliver standard community

equipment within 7 working days, non-standard within 2 weeks and community equipment for supported discharge within 48 hours and end of life within 24 hours. Concerns were raised as the timeline of delivery of standard equipment within 7 working days could be the difference whether a patient stayed at home or went into hospital and it was felt that 7 working days was too long and delivery for all equipment should be 48 hours. Ms Wicks advised that response times had already been greatly improved and currently there is no specification in place so could be held to account without having the specification in place and that this was for the block contract to enable the CCG to get to the place where it needed to be. Mrs Wilde suggested that the CCG could specify that the specification was a stepping stone and give a timeframe to say need to be at a certain agreed place within so many months. Dr Davies agreed could articulate that this was an interim step but could not carry out work around the 7 day service, and cost it up and get ready to put into the contract this year. Dr Davies advised that this needed to be place to enable the CCG to collect data as could not go to procurement historically as the data was unavailable.

5.3 Following discussions it was agreed that there was a need to ensure through the interim

process how were going to achieve the next stage and ensure what was written in the specification with regard to 48 hour delivery times was adhered to and that it was important for correct KPIs to be in place to monitor this and feedback. Dr Davies advised that by having this service in place that it would help achieve data to understand what was going on and could then scope whether there was a need for 7 day working going forward.

5.4 Clinician members asked to see final KPIs to ensure they were capturing correct data. It was

agreed that Clinicians would feedback to Ms Wicks/Dr Davies any comments on KPIs to ensure assurance. Ms Wicks advised of the tight timeframe and would require feedback by midday tomorrow. Dr Davies agreed to circulate summary of the BI measures to the group for comment.

ACTION: Ms Wicks/Dr Davies to circulate BI measures summary to the group. Clinicians to feedback comments with regard to KPIs to ensure progressing forward.

CCC-19/3/027 Additional IAPT Investment 6.0 Dr Davies presented the IAPT Investment paper and explained that it had been identified

within the contract for MPFT next year that there was a need to spend an additional £1.2m in order to achieve the volume and capacity within the service to maximise the turnaround that was required for patients. The Clinical Commissioning Committee were requested to consider the request and give permission for a letter of intent to be sent to MPFT advising them that the £1.2m was in place to enable them to start recruiting immediately.

6.1 Following discussions it was agreed that if the contract was in a position ready for signature imminently then a letter of intent would not be required. Ms Skidmore advised that she was currently liasing with NHSE and was aiming to have everything in place and was hoping the contract would be ready for signature. Dr Davies asked for the committee’s support, if confirmation was not received from NHSE, to support plan B to send the letter of intent.

6.2 Mrs Porter highlighted that under the recruitment section of the report it mentioned recruiting

counsellors that were displaced from the services of GPs and asked for confirmation whether this was realistic. Dr Davies advised that options were there and that they would provide support and development for counsellors that wanted to develop. She also explained that any patient that was currently going through counselling treatment would have their treatment completely finished and that they were not aware of anyone currently waiting for counselling but if there was they will be combined onto a locality waiting list to ensure that they were not put on the back of an IAPT waiting list.

Members agreed to approve the process of sending a letter of intent if the contract was not confirmed and signed.

CCC-19/3/028 Primary Care Strategy (for information) 7.0 The Primary Care Strategy Paper was noted for information only. It was agreed that if anyone

had any questions/concerns to feedback to Mrs Wilde. CCC-19/3/029 Fracture Liaison Service Business Case 8.0 Dr Davies presented a briefing paper for the review of Fracture Liaison Services (FLS) and

advised members that the paper had been presented to a previous CCC and that they had approved the introduction of Fracture Liaison Service and that they have been working closely with the National Osteoporosis Society and have obtained agreement that local providers were keen to provide the service. She advised that the one outstanding issue was that Commissioners would like SaTH to be lead providers and sub-contract the DEXA requirements to RJAH but SaTH had said they would prefer the CCG to commission directly with RJAH.

8.1 Dr Davies highlighted that the reason the business case had been brought back to CCC was because additional information had been identified around the reviewing of prescribing costs and it was now felt that the return on investment would now be longer than the 2 years previous identified and informed that this would now not be until the 3

rd year and asked the

committee for approval to proceed. 8.2 Mrs Porter said that front paper was unclear as it stated that the committee were asked to

advise on the next steps. Dr Davies agreed to amend wording to ensure clarity. Dr Lynch said that she would be keen to obtain clear steer from the committee so that it was clear when receive the challenge back from SaTH with regard to being the prime provider. Mrs Massey advised that there had recently been a change in personnel within the operational structure and informed that she had a call booked with senior manager with regard to taking this forward. It was agreed that the investment still offered a good return and that there was not a material financial problem and members agreed that it was the right thing to do for the patients. Members were supportive.

The Clinical Commissioning Committee noted the contents of the paper and agreed the next steps

CCC-19/3/030 Flash Glucose Monitoring 9.0 Miss Michell-Harding presented the Flash Glucose Monitoring systems policy and explained

that this was being brought to the committee to seek approval for the policy which was in line with NHS England’s eligibility criteria. She advised that the paper had been revised since circulation to members to reflect the NHS wording and a revised copy would be sent to members.

9.1 Miss Michell-Harding advised that the policy had been discussed with the diabetes team in

secondary care and they were happy with the policy in terms of clinical content, structure and the monitoring and regulations that had been put in place in terms of Blueteq regulating the number of patients going on to this but advised that issue they had was to how this would be delivered in Practices. She highlighted that the policy and NHSE guidance referred to the diabetes team but explained that most of the time type 1 diabetes would fall under secondary care even though there may be small cohort of patients that were under diabetic team in the community and because of this secondary care clinicians felt that to ensure that the right people are put onto the right devices and withdraw if not suitable that they would be best placed to deliver this, as they regularly see the patients and that they did not feel assured that this would happen within the community and they had expressed concerns that the policy currently did not specify where it would be delivered. It was proposed to manage NHS England recommendation that patients should be reviewed either when they go for their annual review or when they would present to their diabetes specialist and only at that point would they be assessed for eligibility. Clinicians had agreed with this approach. Miss Michell-Harding said that she would like to compile a communication for distribution around the criteria to ensure everyone was aware how this would be managed. She advised that they were also aware of the extra activity issues and Miss Emberton and Mrs Flaherty were meeting to discuss concerns. It was noted that when monitors are given out patients that they needed to be aware of where to contact if they had problem and would require clear training.

9.2 Dr Sokolov summarised that the policy was clear but the way it was going to be delivered in

terms of impact and additional out-patient activity was yet to be fully understood. Miss Michell-Harding informed that it was with contracting and commissioning teams. As soon as agreed where this would delivered a communication would be sent out so all practices were aware but informed that this would be before 1 April. Members agreed to approve the policy for use

CCC-19/3/031 Sacubitril Valsartan Induction Commissioning Policy 10.0 Mrs Rowland-Jones presented the Sacubitril Valsartan Induction Policy and advised that this

was a new specialist treatment and that SaTH had currently been providing it. She explained that the patient was started on the treatment in secondary care and monitored closely; once the patient was stable they would then be released into Primary Care. Mrs Rowland-Jones informed that the issue was that this was CCG Commissioned but SaTH had said that the drug was expensive and the cost was more than the treatment in out-patients that the CCG was paying for so they were asking for additional funding but, the CCG said that the cost of the drug should be incorporated within these costs. Dr Lewis said she felt that it was SaTH’s responsibility to cover the costs within the tariff received but raised concerns that there was a need to word who was responsible to make decisions within the policy and that it should be a consultant who made decisions and said that she had concerns that if the drug was handed back to the GPs whether this would create an issue around whether GPs were happy to prescribe it.

10.1 Mrs Rowland-Jones informed that if the patient met the NICE criteria then the CCG would be responsible as commissioners. ACTION: Following discussions it was agreed that the committee did not agree to approve the funding of the costs to the provider of sacubitril valsartan for the initiation and stabilisation period. It was agreed that the policy needed to be rewritten as also needed to include within the policy what would happen after the 3 months when released into primary care. It was agreed to take policy away and bring back updated paper to the next CCC for approval

CCC-19/3/032 Any Other Business 11.0 Dr Davies advised that she had met with Telford and Wrekin yesterday re. on-going

alignment to a single VBC policy. A gap analysis had been carried out and she highlighted that there had been a handful of criteria whereby some were tighter within the Shropshire Policy and some were tighter within the Telford policy. It was felt that that the preferred option was still to have a single policy with the tightest criteria across the patch however; the policy had already been taken through and agreed at the Shropshire CCC. Dr Davies informed that Telford and Wrekin would be taking the revised Policy to the Telford CCC next week as need to get a single version agreed policy signed off before the end of March to be able to give the provider 30 days’ notice.

Mrs Angie Parkes had drafted a paper that summarised the changes and this would be

presented to Telford’s PPQ asking them to agree the alignment of the criteria. Dr Davies asked the committee if they agreed to delegate authority to chair’s action to review the revised criteria in Telford and agree a single policy and then this would be brought back to CCC for information as she did not want to delay any further.

Following discussions it was agreed that Dr Sokolov, Dr Pepper and Dr Lewis would review

the single policy via Chair’s action to reach agreement once it had been presented to the Telford PPQ.

Date of Next Meeting

The next meeting of the Clinical Commissioning Committee will be held on Wednesday 17 April 2019 at 9.00am in Meeting Room K2, William Farr House.

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Shropshire CCG Governing Body meeting: 8 May 2019


Name of Committee:

Finance and Performance Committee

Date of Meeting:

6 February & 6 March 2019

Chair:

Keith Timmis, Lay Member - Performance


FPC discussed the new arrangements for the management of the QIPP programme for 2019/20.

There will be more of a joint approach with Telford and Wrekin CCG.

CHC is our most significant internal problem. The QIPP schemes for the new year will need to

be more soundly based than those for 2018/19. The Committee also discussed the potential new

management arrangements for CHC for the new year.

We reported at the last Governing Body meeting that the 2019/20 QIPP plan needs to “quickly

become robust” but there is a lot of work to do before FPC is likely to think we have met that

threshold. That remains the Committee’s conclusion.

We discussed the work being done at STP level to achieve savings. There was limited

information and there is no timetable that might show what impact this will have on the CCG and

when.

The risks to the CCG’s achievement of the control total remain. Even if we achieve our forecast

the underlying position is difficult and poses a challenge to preparing a budget for 2019/20.

There is a dispute with a Welsh health organisation that could pose a further pressure to the

financial position. The Committee asked for further details and stressed the need for clarity on

the year-end agreement of balances exercise to be clear about any financial pressures that

could affect 2019/20.

A&E dominated the performance report again,

Actions required by Governing Body Members: The Governing Body will be considering the financial plan for 2019/20 at this meeting and

should take account of the concerns from FPC about the scale of the challenge facing the

organisation in delivering the proposed control total and associated QIPP target.

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MINUTES OF THE

FINANCE & PERFORMANCE COMMITTEE HELD IN MEETING ROOM B, OAK LODGE, WILLIAM FARR HOUSE, SHREWSBURY, SY3 8XL

ON WEDNESDAY 6 FEBRUARY 2019 AT 1.30PM Present Mr Keith Timmis (Chair) Lay Member – Performance Mrs Claire Skidmore Chief Finance Officer Ms Laura Clare Deputy Chief Finance Officer (Telford & Wrekin) Mr William Hutton Lay Member – Governance & Audit Dr Julie Davies Director for Performance & Delivery Mr Michael Matthee North Locality Chair Mr Kevin Morris GP Practice Board Representative Mr Shaun Eglen Interim Head of PMO Mr Tony Uttley Interim Deputy Chief Finance Officer Ms Sarah Porter Lay Member – Transformation Mr Meredith Vivian Lay Member – Patient & Public Engagement In Attendance Sarah Williams Minute Taker Apologies None received FPC-2019.02.011 - Apologies

1.1 No apologies were received

FPC-2019.02.012 - Members’ Declaration of Interests 2.1 There were no declarations of interest FPC-2019.02.013 - Minutes of Previous Meeting held on 2 January 2019 Please note that, due to no minute taker being available, the previous minutes were transcribed directly from the tape recorded notes 3.1 Item 4.2 – FPC-2018.12.130 – Matters Arising / Action Tracker – change to read: ‘Mrs Skidmore

explained that the first draft of the Budget was not available as the allocations had only been received just before Christmas. Mrs Skidmore explained that the final planning guidance had now been issued and that they were in the process of distilling messages. These would be circulated later in the week.’

3.2 Item 4.4 – agreed to delete as no recollection of this discussion can be confirmed 3.3 Item 5.4 – agreed to delete

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3.4 Item 5.9 - change ‘hostile’ to read ‘challenging’ 3.5 Item 6.2 – remove sentence beginning ‘The agreement made’ and also ‘of true balance’. 3.6 Item 6.4 – ‘rebating’ to read ‘rebasing’ 3.7 Item 6.9 - remove ‘talks were needed’ and replace with ‘this would be considered with NHSE

once Month 9 figures were drafted’. 3.8 Item 7.2 – Figure to read ‘£463,000’ not ‘£163,000’ 3.9 Once the above amendments have been made, the minutes from the meeting held on

Wednesday 2nd January 2019 would be agreed and accepted as a true and accurate record. FPC-2019.02.014 - Matters Arising / Action Tracker 4.1 FPC-2018.12.136 to be deleted 4.2 FPC-2019.01.006 – Due to time pressures & challenges within the team, the run rate had not

been looked at. It was agreed that this will be introduced as part of the redevelopment of the CCG’s financial report.

4.3 Tracker was discussed and updated as appropriate. Action: FPC -2019.01.006 to be kept as an action

FPC-2019.02.015 – Quality, Innovation, Productivity & Prevention (QIPP) Update QIPP Assurance 5.1 Mrs Skidmore highlighted to the Committee that there had been a downturn noticed in the

reported forecast out-turn between Months 8 & 9. Nothing has been done differently, but challenge process through last period has meant some schemes have been crystalized that were being risk assessed into the position. The two key drivers for downturn are as follows.

5.2 MSK – work has been taking place since Christmas to better understand the deterioration. In

previous forecasts, the Programme Manager has been assuming a level of improvement at the back end of the year as a result of some of the actions that have been taken – what we’re seeing now is that some of the turnaround time for these actions to bed in is taking longer than anticipated. Mrs Skidmore is relatively confident that this assessment now won’t move again, as model assumptions have been run through.

5.3 A formal Transformation Board is in the process of being established, with the intention of

having more senior (Executives / Accountable Officer) buying into this process so, if future deterioration is forecasted, we have an AO / Chief Executive sighted as soon as possible in order to be part of the solution a lot earlier.

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5.4 CHC – there are still staffing issues within the team due to sickness and vacancies etc. It is incredibly difficult to deliver ‘business as usual’, let alone deliver on QIPP schemes as well. The two main areas of concern are slippage on Hospice at Home which is as a result of a deterioration of negotiations with the Hospice regarding the contract. The other issue is the review of PICU (Psychiatric Intensive Care Unit) at MPFT. There is a broader plan for PICU in the plan for next year. This will address some of the more challenging issues around out of area placements and getting the right placements for people in general.

5.5 Mr Morris expressed concerns that talks and meetings are taking place regarding MSK and

PICU, but that no reports / actions are being seen or done. No support is being received for the PMO. Mrs Skidmore informed the Committee that the Head of Service has been on long-term leave with no sign of a return date and this is definitely one of the areas of concern in respect of leadership. There has been good managerial leadership in the interim and Brett continues to do a good job as Business Manager, but there is an urgent need for a clinician. Someone has started in post to ‘bridge the gap’, but her mandate is to embed the policy and process that has been drafted (signed off at Quality Committee last week).

5.6 Mr Timmis expressed a high degree of concern regarding the amount of QIPP that was in the

4th quarter – especially with discussions that have taken place outside the Finance Committee. Focus is, as expected, on 2019/20 schemes so the degree of scrutiny on 4th quarter is, understandably, less and we are therefore less able to deliver the Quarter 4 schemes. Lots of schemes have been pushed back; performance is going to tail off towards the end of the year. We have been told that we have never been so well prepared for QIPP as in the current year, but nothing feels different to 2017/18. We need to understand why we’re not delivering – too many priorities? Not sure of what is expected?? Too late to affect the delivery of this year’s plans. Even if we are able to delivery £16m worth of QIPP, we still need to question how to manage that programme and forecasting.

5.7 What are QIPP management arrangements from 1st April onwards? There are several people

who have been taken on as a result of the NHS England funding, but there is uncertainty about the future. Are we going to be on the back foot immediately? Mr Timmis is looking for some reassurance as to what the management arrangements are for QIPP. This concern is exacerbated by the potential distraction of organization change as we seek closer working arrangements with T&W CCG.

5.8 Mr Morris also raised a concern with Mr Timmis several months ago around clarity around QIPP Programme Board. Need to ensure this arrangement works. Mr Morris commented that things have changed several times, in quick succession.

5.9 Mr Timmis expressed concern at the amount of money that has been spent on QIPP management arrangements which has not produced a permanent benefit in our ability to manage QIPP.

5.10 Mrs Skidmore replied that significant exit of resources will happen at year end. This is something that is to the fore of her mind. Part of Shaun Eglen’s remit, prior to 31st March, is to bring together a report, with Telford, as to ‘what the future looks like’. A meeting to discuss the same has been scheduled for w/c 11th February.

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5.11 Mrs Skidmore commented that there are ongoing discussions asking what is PMO for us? Do we have the right people doing the right tasks because we might want to deploy our resources differently in terms of, say, Dr Davies’ team – do we need more people ‘on the ground’? This may not be more people doing the actual commissioning specification task, but embedding more people in the business case writing etc.

5.12 Mrs Skidmore confirmed that she shares the Committee’s concerns regarding what we’re delivering. The ‘ask’ is huge and not getting any better. We have to be realistic about what we are doing and how we prioritise that. Dr Davies added that we have learned that, due to the scale of the challenge re MSK, we can be fighting at a certain level to make a transformational change, but we just can’t make it happen. MSK is case in point – all risk is sat with the Commissioner. If we had a functioning STP, the risk would have been shared more uniformly than it actually was. A 54% reduction in orthopaedics can be demonstrated in new outpatients this year. The referrals from Primary Care have decreased, but the provider is still showing excessive waiting lists.

5.13 The landscape under which we’re trying to deliver QIPP needs to change. Providers and Commissioners must work together to avoid more financial crisis within the system. Dr Davies expressed anxiety about, particularly, the strategic direction of RJAH and their genuine plan for the future needs to be understood.

5.14 We are still a significant outlier for orthopaedics. RJAH have to demonstrate that they are part of this system and acknowledge that the current level of spend on MSK is unsustainable for our system. If they refuse to recognise that and will not accept steps towards a capitated budget, then we have to be brave and stand firm.

5.15 Mr Timmis recalled a conversation from 2 years ago discussing options on how to tackle this issue and one option was to give it to a third party provider.

5.16 Dr Davies confirmed that the specification has been re-written this year, which has been shared with the provider. Equivalent models compared to ours show that RJAH have two choices as a specialist orthopaedic provider – they either embrace this as part of the future or we go to the market. This option needs to be strongly reiterated to the Provider.

5.17 Following the GP Open House meeting this morning where Mr Timmis mentioned the same, he again commented to the Committee that he felt that we would not be able to deliver our target in 19/20.

5.18 Mr Vivian picked up Dr Davies’ point about ‘being brave enough’. He asked that the Executives tell us ‘when the time has come’ so that we can back up the decisions.

5.19 Dr Davies reported that the third PIG (Project Implementation Group) meeting for Care Closer to Home took place yesterday (05.02.19) which is about getting the demonstrator sites up and running. Pleased to report a really successful meeting and selected two demonstrator sites and two control sites. It was very helpful to have the MPFT (Midlands Partnership Foundation Trust) in the room and the sites are committed to start operating before the end of February. Agreement of specifications of what we want to commission, rather than what they want to provide has now been resolved. IDT (Interdisciplinary Team) spec which has been in the contract, but has been refused to be delivered, has been gone through specifically and Dr Davies will be bringing this issue to a meeting tomorrow.

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5.20 All these issues will be considered as part of the agreement of our QIPP and budget for the new year.

PLANNING & BUDGET UPDATE FPC-2019.02.016 – 1920 PLAN 6.1 Mrs Skidmore distributed a slide deck to the Committee and a discussion took place. 6.2 The pack was the one taken to NHS England by Mrs Skidmore and Mr Simon Freeman on

Friday 1st February – as they were interested in 18/19 and our early thoughts were for 19/20.

6.3 Mrs Skidmore wanted the Committee to spend a little time on 18/19 in order for them to understand the underlying position– this makes a big difference when we look at what next year will look like. The Committee noted the underlying position has worsened.

6.4 Control totals are set at a point in time and the true extent of the deterioration doesn’t manifest itself until after these are set. At the meeting with NHS England on Friday it was recognised that, given the change in circumstances, it is understandable why we are now saying we’re unable to deliver what the ask is.

6.5 Budgets are started with the exit positions from the previous year i.e. what was our outturn from 18/19 that is recurrent and will continue and then how do we need to build that to get our budget for the new year? They are built with as much information and data as possible; assumptions around price growth are taken into account, along with demographics and growth factors. Each point of delivery has an assessment of growth factored in also.

6.6 A picture is built of what we think our spend looks like before we try to make any intervention to get it back to the pot of money that we’ve actually got to spend. The gap between that and the actual allocation given to us is the QIPP figure we need to aim for.

6.7 Mrs Skidmore wanted to talk about the allocation received. Press coverage reported all the money that was going into the NHS – our CCG was allocated very slightly less than the national average for 19/20. This can’t be influenced at all – it is a funding formula based on need. Unfortunately, Shropshire CCG isn’t deemed ‘rural’ enough to benefit from the rural top-ups available to other CCGs like Cumbria.

6.8 We have been given, in relation to other years, a lot of money – in excess of 5% growth. The problem we have is that the ask of us, that has come through the Long-Term Plan, far exceeds what that allocation gives us. Members will have seen in the LTP this desire to bring provider trusts out of financial deficit. Mrs. Skidmore discussed with the Committee the large amount of money that is flooding out of the CCG into our providers.

6.9 Table on Page 18 was explained by Mrs Skidmore and shows how the £22m allocation is split up and also how quickly it is used up. Early estimates are that, in order to meet the requirement of the Mental Health Investment standard, we need to add on top of our growth & inflation another £1.4m.

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6.10 In order to meet the new IAPT (Increased Access to Psychological Therapy) standard, we need to move our target achievement from 19% to 22%. That move alone costs us approximately £200k. We also need to put £200k into eating disorders. Mr Matthee raised a question that will be dealt with outside of the meeting regarding the money that was being given to the providers. Dr Davies will discuss.

6.11 GP Forward View – over the past 2 years, we have had to invest £3 per head of population into Primary Care. This was done on a non-recurring basis, split over the 2 years (£1.50 per head per year) with a total spend of approximately £450k. When the guidance came out, it was required for us to crystalise that figure as a recurrent sum and it is currently showing as £1.50. We had already budgeted for this recurrently last year, so we don’t have to show again in this presentation.

6.12 Growth and inflation column shows a figure of £34m against £24m allocation. The biggest assumption is what the impact is of the new tariff that is being applied for 19/20 – there are some significant differences to how the tariff has been set for this year. Consultation is just closing and confirmed final numbers are awaited. The computed impact for our CCG of that, is currently £11m.

6.13 Other recurrent investments – 4 items in this column. The numbers against ‘running costs’ and ‘co-commissioning’ are purely the allocation uplift figures. Extra spending needs to be reflected. Committee would be interested in two items of new investment - Continuing Care which is £300k – finance have decided to build this in as there is a cost risk for TCP (Transforming Care Partnership). So far, we haven’t had too many patients transition, although at some point they will do so and will be under our care. Experience and evidence from other areas tells us that the money that comes with these patients from specialised services isn’t as much as the care packages needed for them, so the £300k does not look sufficient, but needed logging to flag a potential issue.

6.14 The other amount is £850k against the acute line – this is an estimate. In the process of changing the contract we currently have with IMH for the GP practice they run and the streaming service at SaTH. All of that, at the moment, is paid for by the delegated co-commissioning budget and it’s an historic arrangement that was there. The re-procurement process separates the GP and streaming sides. Whatever happens to the GP list remains under the delegated budget, but the streaming service will need to be funded from the programme budget (approx. £800k on what is already in the budget).

6.15 Contingency reserve has had to be re-established (£2.3m goes back in).

6.16 All of that spend profile built up means that, if we were to try to achieve our control total of £12.3m deficit, we would have to generate a QIPP of £27.7m. This is without the £4.8m that still might go on top. Current QIPP plan (pre £4.8m) would leave us with £10.3m of QIPP with absolutely no plan as we stand today.

6.17 Mrs Skidmore and the Committee agreed that the ‘ask’ will not be achievable.

6.18 Mr Vivian asked what do NHS England expect us to do knowing the situation we are in? Mrs Skidmore felt that expectation is around ‘don’t just tell us you can’t do it, tell us what the longer-term plan is to give assurance that you will get it back’. Mrs Skidmore said there will be further conversations over the next couple of weeks.

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6.19 The long-term financial plan also needs to be refreshed and a reasonable view of what we can achieve, and when, needs to be constructed.

6.20 Mr Vivian asked if NHS England wanted us to present a £12.3m budget with a £30m QIPP included? He felt that this would be misrepresenting our position. Mrs Skidmore said she did not want to do this, but include the QIPP we know we can achieve.

6.21 Dr Davies reiterated that she didn’t know where this sort of figure would come from. Her team have exhausted all options.

6.22 Mrs Skidmore will take the two slides discussed today to the Governing Body meeting next week and will also take a one-sided A4 outline summary for the QIPP programme. Dr Skidmore and Dr Simon Freeman need to get more information from NHS England as to what the expectations are.

6.23 Working summary document (work in progress) was distributed to the Committee for discussion.

6.24 Mr Mattee asked if QIPP cannot be done with regards to hospital’s diabetes medication / monitoring?

6.25 The Committee all agreed that the position did not look good and that ‘something had to give’. It was also agreed that we were in no position to set a budget.

Action: 6.24 - Mr Eglen to report back to next FPC (6th March) to confirm if we have robust

business cases and that discussions have progressed with providers?

FPC-2019.02.017 – Programme Budgeting Benchmarking Report 7.1 Mr Uttley gave a brief background to the report. Each CCG is asked to split expenditure by

programme and an interesting data set is created. The report shows the current position of Shropshire CCG in comparison to others who have completed the exercise and also 10 CCGs similar to Shropshire. Three main areas of expenditure:

- Acute - Mental Health / Learning Disabilities - Other

7.2 Currently in the highest quintile (nationally) for ‘acute’, in the middle for Mental Health /

Learning Disabilities as well as ‘other’.

7.3 The Mental Health / Learning Disabilities area is unusual as the number of individuals involved is so small, the data is expressed on an adjusted population basis – whereas all the other expenditure in the other two areas is expressed per 100,000 population basis.

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7.4 When compared to similar CCGs, on ‘acute’, we are the 3rd highest. Mental Health / Learning Disabilities, we are the lowest in comparison. Mr Uttley asked the Committee if they felt that deep dives into this data would be useful. The Committee agreed with Mr Timmis mentioning that we are obliged to do so for the Governing Body as it is in the Terms of Reference for this Committee.

Action: Mr Uttley bring a follow-up benchmarking paper to FPC in March

7.5 Dr Davies expressed real concern about the Mental Health position. Trying to plan for next

year, but how ambitious can she afford to be? Scenario planning is underway for all levels of provision of care.

FPC-2019.02.018 – Finance & Contracting Report 8.1 Mr Timmis felt that there was an issue with the overall summary and the clarity of key

messages and how much we are going to miss the control total by. Assumptions can be made, but with messages going to the Governing Body, points need to be crystal clear and concise and also in plain English. Frustration was also noted as this was the third month running that this observation had been made. This ‘clouded’ summary has led, in the past, to some confusion – for example several people in meetings have quoted differing figures as to how much the control total was going to be missed by.

8.2 Mr Timmis also felt that the tone of the report sounded more positive than anyone believes.

These reports should be written with a greater degree of realism. 8.3 Mr Timmis mentioned the report said a notice was served on RJAH contracts and asked for

clarification. The Committee felt that this wasn’t the case. Dr Davies said there were performance notices but nothing more formal.

8.4 CHC was again mentioned. The fact that we’ve had information provided to the Business

Manager, but not reported to Finance is completely unacceptable. This matter was raised at the Audit Committee before Christmas. Mr. Matthee asked if there was not a duty of care for this information to be provided? There is a long-standing cultural problem with CCG about not following controls and CHC have had a series of damning internal audit reports (and flagged up by external auditors) for inaccuracy of information.

8.5 Mr Hutton commented that, during the internal audit, some positive movement had been

noted, but there was a question around the sustainability of that. 8.7 Mr Timmis raised the issue of the Agreement of NHS Debtors & Creditors, which was a key

criticism from Grant Thornton last year. Significant, but not material, differences were found. Mr Uttley commented that it was the process that they couldn’t see the evidence that it had been followed. Mr Timmis asked that future reports be made available to the Audit Committee later this month.

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FPC-2019.02.019 – Performance Report 9.2 Mr Timmis raised a question that had been asked by Dr Finola Lynch – following her

attendance at a SaTH meeting, where Tony Fox was quoted as they are ‘looking into the role of ShropDoc and NHS 111 in terms of ambulance dispositions’. Dr Lynch had raised this with Mr Timmis a couple of weeks ago that this wasn’t consistent with what they had been told at previous FPC meetings. He has reiterated to Dr Lynch that ambulance dispositions from NHS 111 are reported to FPC as “stable”.

9.3 Dr Davies confirmed this. She also highlighted that, for the first time in this report, she now

has a separate group looking into ambulance demand. 9.4 Ambulance demand into Emergency Departments across the region, but even more so ours,

has gone up this year and this increase is being investigated. What we are seeing is the relative dispositions from 111 are no higher for us than anywhere else. The biggest increase is within 999 and we are now going back to ascertain why, what can we do, what are alternatives?

9.5 This is our first winter with NHS 111 in Shropshire rather than it all going through the out of

hours provider. Flowchart has been done to map all the data through the system, so we can track all of the dispositions and how patients can access an ambulance and then how that works through.

9.6 There is a working hypothesis that we are having a ‘perfect storm’ on a Sunday. We know the

clinical staffing model within ShropDoc is not as GP heavy as it used to be and on a Sunday, demand in general from the public is increasing, (also for 111 and out of hours).

9.7 Mr Morris questioned if we were paying ShropDoc and 111 to triage. Are we double-paying?

Is this also why the pressure is on? Dr Davies confirmed that this is what they are investigating. Report will feed through to A&E Delivery Board.

Action: Dr Davies to report on results of ambulance disposition analysis.

9.8 Mr Timmis raised the issue of cancer diagnostics concerns. Given SaTH’s history of not

delivering on action plans, what credence can be given to them saying that they have a plan on how they’re going to improve their cancer performance. Dr Davies replied that the level of granularity in the action plans is not where she wants it to be. Dr Davies, along with David Whiting and colleagues from Telford & Wrekin have gone through the plan line by line – have fed back. The plan is the best to date, but needs to be better, which is known. Support from NHS England on a fortnightly call to help drive improvement and hold them to account. Some will be a challenge and some is beyond SaTH’s control.

9.9 Need to work smarter predicting cancer prevalence and plan the diagnostic capability. 9.10 62 day will be more of a challenge although improvement is expected.

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FPC-2019.02.020 – Key Messages to the Governing Body 10.1 The key messages for the Governing Body were noted as follows:

CHC Issues

QIPP & Budget impact

PMO Function

FPC-2019.02.21 - Any Other Business 11.1 The Committee was reminded that Shaun Eglen leaves his post at the end of March 2019. No

replacement has been confirmed. Mr Morris expressed concern about this. Mr. Eglen informed the Committee that he was preparing a paper regarding the short-term implications. This would be submitted to the Committee as soon as possible, but he warned that splitting the PMO function over two CCGs would only work in the very short-term.

Date and Time of Next Meeting Wednesday 6th March 2019, 1.30pm – 3.30pm in Meeting Room B, William Farr House. Please forward any apologies directly to Sarah Williams ([email protected])


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MINUTES OF THE FINANCE & PERFORMANCE COMMITTEE

HELD IN MEETING ROOM B, WILLIAM FARR HOUSE, SHREWSBURY, SY3 8XL ON WEDNESDAY 6 MARCH 2019 AT 1.30PM

Present Mr Keith Timmis (Chair) Lay Member – Performance Mrs Laura Clare Deputy Chief Finance Officer Mr William Hutton Lay Member – Governance & Audit Dr Julie Davies Director of Performance & Delivery Dr Michael Matthee North Locality Chair Mr Kevin Morris GP Practice Board Representative Mr Shaun Eglen Interim Head of PMO Ms Sarah Porter Lay Member – Transformation Ms Kate Owen Joint PMO In Attendance Apologies Mrs Claire Skidmore Chief Finance Officer Mr Meredith Vivian Lay Member – Patient & Public Engagement FPC-2019.03.021 - Apologies

1.1 Apologies were noted as above

FPC-2019.03.022 - Members’ Declaration of Interests 2.1 There were no declarations of interest. FPC-2019.03.023 - Minutes of Previous Meeting held on 6 February 2019 Please note that, due to no minute taker being available, the previous minutes were transcribed directly from the tape recorded notes 3.1 A discussion relating to the value of the Meeting Summary documents took place

with feedback requested by Mr Timmis. 3.2 The Minutes from the meeting held on 6 February 2019 were then agreed as a true

and accurate record.

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FPC-2019.03.024 - Matters Arising/Action Tracker 4.1 Mr Timmis would like it minuted that this was to be Mr William Hutton’s last F&P

Meeting after 12 years and thanked him for his contribution on behalf of the Committee.

4.2 Mr Timmis advised that Mr Uttley’s report on NHS debtors and creditors went to the

last Audit Committee Meeting and was reviewed there. The external auditors had advised they would be looking closely at how the debtors and creditors exercise has been done due to the financial implications involved.

4.3 FPC-2018.11.120 – Matters Arising/Action Tracker - Mr Timmis requested that the

deep dive programme be discussed at the May meeting as per the Action Tracker.

FPC-2019.02.017 – point 7.4 Benchmarking: Mr Timmis advised that he had been in discussion with Miles Scott who has attended the QIPP Programme Board. Mr Timmis was happy to send out the report from Miles if it would be of value. It was agreed that Mr Timmis would send it out tomorrow for Committee Members to review and follow-up in the future.

Action: Mr Timmis to issue Benchmarking Report to FPC Members. Members

to review and feed back for April FPC

FPC-2019.03.025 – Quality, Innovation, Productivity & Prevention (QIPP) Update 5.1 Mr Timmis shared the concerns of several Committee members about the

arrangements for QIPP and asked for further discussion and greater clarity around what the position actually was.

5.2 Mrs Clare advised that the Finance Team across Shropshire and Telford were

moving forward in working together to increase efficiency and avoid duplication. A discussion took place relating to low executive attendance at QIPP Board Meetings and how this could be improved, as well as getting a full understanding of the management arrangements. Mr Morris expressed his concern about the impact of low executive “buy-in” to the QIPP process and his role as Chair of the QIPP Programme Board. Mrs Clare advised she had a structure diagram outlining the new arrangements and Mr Timmis requested that Mr Morris review this with Mrs Skidmore and Ms Owen and report back to the FPC April Meeting.

Action: Mr Morris to consult with Mrs Skidmore and Ms Owen on Mrs Clare’s

QIPP management structure diagram and report back for April FPC 5.3 Mr Timmis asked for clarification on what the final QIPP figure was likely to be and

Mr Eglen confirmed it was approximately £16m. Dr Davies confirmed that MSK was going in the right direction and that the weekly dashboard had improved three weeks in a row.

5.4 Mr Timmis highlighted the CHC report concerning problems with information from

CHC going to Finance and PMO. Mr Eglen advised the first set of monthly reports &

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Businesses Cases were received last week and were being reviewed by the Finance Team, due for completion at the end of the week. There were still issues with Oracle vs. Broadcare.

5.5 Mr Timmis advised he had spoken to David Stout, Interim AO, about MSK and Mr

Stout had advised his focus would be on ensuring that the CCG just manage and deliver the areas they could.

5.6 Mr Timmis asked for clarity on a couple of areas in the most recent report. Para.8

referred to the Alliance Agreement and Mr Timmis wanted to understand why CCG were not getting the £500k detailed. Dr Davies explained this could not be delivered but was unsure on the figure negotiated.

5.7 Concern was shown by Mr Timmis in relation to para.31 of the report concerning the

need for a Transformation Board for MSK.

5.8 Dr Davies advised that the delivery of the new model of care for musculoskeletal commissioned via SOOS at Robert Jones had been difficult, feeling that the Trust had not quite appreciated the scale of transformation required. This had been escalated to Dr Simon Freeman who had discussed with his counterpart at RJAH and agreement had been made to arrange a Transformation Board of Accountable Officers and Clinical Leads to drive this forward. Dr Davies will take the draft papers to the Board next week which stresses the importance of the delivery of this model from RJAH.

5.9 Dr Davies confirmed that the draft paper being taken to the Governing Body next week would detail the timescale available to the Trust before the CCG made a decision over future procurement intentions. Members agreed this was the last opportunity for RJAH to demonstrate it could be part of effective transformation of MSK services.

5.10 Mr Hutton requested that any unallocated QIPP in the new plans should be presented with performance against modified plan rather than original plan.

5.11 The Committee discussed the current state of STP savings plans (as far as members were aware of them). Approximately £25m has been identified but the plans are described as vague. Mr Eglen said he considered there were elements of double counting in the summary he had seen.

Monthly Monitoring for Finance and Performance FPC-2019-.03.26 – Finance and Contracting Report 6.1 Mr Timmis advised he felt the Finance Paper still lacked sufficient transparency

particularly with the impact of risk areas on the reported Control Total. He referred to £4m from NHSE and the receipt of CSF money but still missing the target by £5m and that this message was unclear in the paper. Mr Timmis explained to the group that he had feedback from GPs on the lack of induction to the Governing Body in relation to finance and that the Executive Summary needed to be clearer so all Governing Body members were clear on the financial information presented to them.

6.2 Mr Timmis also told the group that the Audit Committee had received Deloitte’s report

regarding the Finance Action Plan and they had highlighted the description of the

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reserves as being weak which the FPC had commented on in the past. The descriptions were brief and do not give a full picture.

6.3 Mr Timmis consulted the Committee about the concern over the Betsi contract regarding what was being paid and what was due. Back in January it was raised that there could be a £2m-£3m problem due to current arrangements. Mr Timmis asked if any conclusion had been reached with the negotiations. Mrs Clare responded that she did not think there had been a conclusion reached and that discussions were ongoing. Mr Timmis explained that his concern related to this potential shortfall not being reported in the Finance Paper and he would like to understand the significance of it.

6.4 Mr Morris raised a report about monetary support that Shropshire CCG receives that is not reflected in the Finance Paper e.g. £850k coming from Telford. He felt the paper should clearly reflect the terms i.e. whether the money is repayable or a gift and where the liability lies. A discussion continued around this matter with several members suggesting that communication needed to improve in order to facilitate awareness amongst FPC members.

Actions: Mrs Clare to identify the final settlement and financial impact of the Betsi contract ready for the April FPC meeting.

Mrs Clare to clarify with Mrs Skidmore and include information on all monetary support and terms in the

April FPC report..

6.5 Members’ feelings on the clarity of use of reserves in the Finance Paper and how these could be shown more transparently was discussed. Mrs Clare agreed to improve the clarity in her changes to the format of the financial report in the new financial year.

6.6 Dr Matthee asked a question relating to CQUIN payments being paid when targets had not been met. Dr Davies explained that it depended on the terms of the year-end settlement agreement.

6.7 Mr Timmis referred the group to P.10, para.2 and read from the report, “and additional expenditure itself not previously reported in the position” and asked for clarification on why there was additional expenditure for SaTH when a year-end agreement was in place.

Action: Mrs Clare to research reasons for additional expenditure at SATH when

year-end agreements are in place

6.8 Mr Morris asked a question about CCG running costs and what figure the 20% was

based on. Mrs Clare clarified that NHS England’s 20% reduction in running costs was based on the 2017/18 expenditure and CCG have the allocation for next year and 2019/20. This would be discussed later on the agenda under ‘Planning Report’.

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FPC-2019.03.027 – Performance Report 7.1 Mr Timmis raised a question relating to ShropDoc and the Out-Of-Hours service, as

well as A&E. Dr Davies advised the group that A&E performance for Jan 2019 had seen an improvement on Jan 2018 and that she would now report to the Committee on an overall snapshot of the position against key targets and an update on the previous action relating to the deep dive analysis on ambulance demand.

7.2 Dr Davies reported on ambulance demand, first reporting a significant increase in conveyances, particularly during December 2018 and January 2019. This had had a significant impact on increasing the over 30 mins and one hour handover delays. Previous forecasts compared with actual had been as expected but the analysis initialy appeared to highlight an issue around 111, with a higher disposition of ambulances via 111 than previously through out-of-hours/ShropDoc. Dr Davies advised that the analysis of Urgent Care Demand was difficult due to its complexity and a simple cause-and-effect could never be found. Dr Davies confirmed that the ‘See and Convey’ rates had definitely increased so time of day for demand needed to be analysed. There had been an increase in out-of-hours demand on a Sunday and Thursday and the group needed to examine reasons for this. Dr Davies clarified that the first phase showed that 111 had not materially increased demand, demand had just moved from 999 to 111. The current system would not cope with the same level of increase in demand next winter as it had had this winter. Dr Davies advised that the analysis had been agreed and signed off by both CCGs, SaTH and the Ambulance Service so provided a system wide single version of the truth.

Action: Dr Davies to report further developments on ambulance demand data at

April meeting. 7.3 Mr Timmis summarised that it was positive news that a common understanding of the

data had been accepted by the CCGs, Ambulance Service and SaTH, that the introduction of NHS 111 had not materially increased dispositions and that we had further work planned to look at some of the underlying causes.

7.4 It was agreed that referrals to ‘ShropDoc’ would be removed and changed to ‘Out of

Hours’ as the contract was no longer with ShropDoc but with SCHT. 7.5 Mr Timmis requested that the meeting now consider the issues relating to the ‘Out of

Hours’ service that had arisen in the morning’s meeting, namely performance deterioration, a data quality issue and a financial sustainability issue. and the Committee requested an update from the Community Trust at the next meeting.

Action: Dr Davies to report on update from SCHT on out of hours service issues

at April meeting. 7.6 Mr Timmis asked Dr Davies for an overview on issues with cancer diagnostics and

the action plans. Dr Davies advised the meeting that the CCG had turned a corner in the last 6-8 weeks with detailed Tumour Site Recovery Plans for all Tumour Sites with the exception of Urology, as well as improvement in the overall two-week performance and the two-week breast performance and will continue to do so. The Trust were confident and had reintroduced a lot of scrutiny around their patient-tracking list for cancer, and controls have been put back in place and improvement could be seen. Agreement had been reached with NHSI to deliver two-week targets at the same point as the 62 day from July 2019.

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7.7 Mr Timmis asked if there were any quality issues to consider at this level of

performance. Dr Davies confirmed that this was reviewed through the Planned Care Working Group and anything identified was escalated to the Clinical Quality Review.

7.8 A member asked Dr Davies if there was a reason there was still a problem with

urology. Dr Davies advised that the problem arose from developments in the specialty; all qualifying urologists were being trained in robotic surgery and not all hospitals were able to host a robot yet, including SaTH. This meant that hospitals who do not have a robot found it difficult to recruit as newly qualified urologists were trained to work with robots. There were also certain procedures that a robot could not be used for, so the whole issue was not just SaTH, it was a regional, and possibly national, issue. This was being addressed through SaTH writing formally to NHSI to highlight the issues and that it is beyond their individual control and they needed support. SaTH had signed a Memorandum of Understanding with UHNM to clarify how to make a partnership work so that local patients requiring additional interim robotic surgery could have this done at UHNM. This would provide UHNM with the economy of scale that would allow them to write a Business Case to get a second robot, the benefit to SaTH being that their surgeons and workforce could help to support SaTH with surgical procedures. The process had been started in asking some SaTH patients to transfer to UHNM for robotic surgery, but a lot of patients seemed to be reluctant to do this, preferring to remain with the local surgeon, so this needed to be addressed.

FPC-2019.03.28 – Planning and Budget Update – 1920 Plan 8.1 Mrs Clare advised the Committee that the paper presented was based on the 12

February submission and things had been updated already. 8.2 Mr Timmis addressed the group to gain agreement for a further discussion on this at

an internal meeting with himself, Mrs Skidmore, Mr Morris and Mrs Clare in advance of the Governing Body meeting next week. Mrs Clare also clarified that the £5m deficit mentioned in the Finance Plan was not included in the figure shown in the 19/20 Plan available to members at the meeting, but had been included in the figures submitted to NHS England that day.

8.3 It was agreed that clarity of information was required in all areas for the Governing

Body at the meeting on 13 March 2019. FPC-2019.03.029 – Key Messages to the Governing Body 9.1 The key messages for the Governing Body were noted as follows:

QIPP PMO management arrangements need to be agreed.

MSK review of SOOS at RJAH is at the “last chance” stage.

To review and clarify any significant risk associated with Betsi contract.

Greater clarity on non-recurrent support including from T&W.

Concern relating to the issues around the Shropcom Out of Hours Service.

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Having updated budget information in preparation for discussion next Wednesday at the Governing Body meeting.

FPC to review reserves and year-end agreements in the new year, particularly in relation to Shropshire CCG being advised of an overspend on SaTH when a year-end agreement has been in place.

FPC-2019.03.030 - Any Other Business 10.1 Mr Timmis advised the Committee that this was his last time chairing FPC and

thanked everybody for all their support over the last two years. He said the last two years had been difficult at times but he was very grateful for everyone’s input.

Date and Time of Next Meeting Wednesday 3rd April 2019 1.30pm – 3.30pm, Room A, William Farr House

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Shropshire CCG Governing Body meeting: 13 March 2019


Name of Committee:

Primary Care Commissioning Committee

Date of Meeting:

6 February 2019

Chair:

Keith Timmis, Lay Member - Performance


GP Forward View work continues to make progress. PCCC discussed the implications of the

Long Term Plan on the Committee’s work and agreed criteria for the GP retention scheme to

support the workforce we will need to deliver primary care.

The Committee outlined comments on the draft business case for the Shifnal medical practice. A

revised plan will come back to the Committee once queries have been answered and there is

clearer evidence of how the scheme will be transformational.

We agreed that the Primary Care Working Group would no longer meet as its work is now part of

the work of other groups and processes.

We noted the agreement of a new GMS contract.

NHSE have made some further suggestions for the PCCC terms of reference. The Director of

Corporate Affairs and Director of Primary Care will liaise over any changes that are needed.

Actions required by Governing Body Members: None.

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MINUTES OF THE PRIMARY CARE COMMISSIONING COMMITTEE (PCCC) HELD IN ROOM K2, WILLIAM FARR HOUSE, SHREWSBURY AT 10.00 AM ON

WEDNESDAY 6 FEBRUARY 2019 PART 1 MEETING

Present Mr Keith Timmis Lay Member, Performance (Chair) Mr Meredith Vivian Lay Member Mrs Nicky Wilde Director of Primary Care Mrs Rebecca Woods Head of Primary Care for Shropshire & Staffordshire, NHS England Mrs Claire Skidmore Chief Finance Officer Mrs Sam Tilley Director of Corporate Affairs Mr William Hutton Lay Member Mrs Sarah Porter Lay Member Dr Stephen James GP Member Dr Colin Stanford External GP Member Kevin Morris Practice Member Representative In Attendance Mrs Amanda Alamanos NHS England Primary Care Lead, Shropshire & Telford Mr Steve Ellis Head of Primary Care Mr Ashley Seymour Assura Medical Dr Philip Leigh Shifnal Medical Practice Cllr. Lee Chapman Shropshire Council Ms Vanessa Barrett Healthwatch Shropshire Mrs Chris Billingham Personal Assistant, Minute Taker Apologies Ms Dawn Clarke Director of Nursing, Quality and Patient Experience Dr Deborah Shepherd GP Member, Shrewsbury & Atcham Locality Chair Dr Jessica Sokolov Medical Director PCCC-2019-02.001 - Apologies Apologies received were recorded as above. PCCC-2019-02.002 - Members’ Declaration of Interests Mr Hutton referred to a potential conflict of interest regarding an item on the Agenda relating to the GP Retention Scheme. Mr Timmis agreed that when this item was discussed any GPs present would be asked to leave the room. Dr Stanford and Dr James would therefore not be involved in the discussion relating to this item. There were no other declarations of interest. PCCC-2019-02.003 – Minutes of Previous Meetings held on 5 December 2018 and 2 January 2019 and Matters Arising The Minutes of the Part 1 meeting held on 5 December 2018 were agreed as an accurate record, provided the following amendments were noted:-

Ms Barrett had attended the December meeting but her attendance was not recorded.

Ms Barrett’s name was spelled incorrectly.

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The Minutes of the Part 1 meeting held on 2 January 2019 were agreed as an accurate record provided the following amendments were noted:-

Dr Colin Stanford’s name was spelled incorrectly.

The statement made by Dr Stanford on Page 3, Paragraph 7 should read “Neither option fitted with either our local plans or national plans”.

Matters Arising The meeting agreed that most of the outstanding actions should be closed as they have either been overtaken by subsequent meetings, or they are Agenda items. However, an update was requested from Mrs Wilde on the following:- PCCC-2018-12.175 Mr Timmis requested an update on the action for Mrs Wilde to establish the impact of new CQC inspection arrangements for groups of Practices and report to the Committee. Mrs Wilde advised that Mr Ellis is meeting with CQC during week commencing 11 February 2019 and would be able to provide an update at the next meeting. PCCC-2018-12.180 Mrs Woods referred to her request for information regarding the contents of the National Audit Office report on Capita. The official communication received from NHS England nationally was that there would be another submission to the Public Accounts Committee in January which would provide an update on progress against the initial National Audit Office report. Mrs Woods will share conclusions and minutes of that meeting with the Committee when received. Mr Timmis expressed concern as to whether Capita had the ability to improve the service. It is the CCG’s responsibility to ensure that concerns expressed by local Practices regarding poor service are fed back to Capita. The CCG must also ensure that improvements are instigated. Mrs Wilde advised that the CCG had invited Capita to Shropshire to speak to Practices directly during week commencing 11 February 2019. Questions from Practices have been shared with Capita in advance. ACTION: Mrs Woods to share minutes of the January Public Accounts Committee and any conclusions from that meeting with Committee members. PCCC-2019-02.004 – Public Questions No questions were received from members of the public. PCCC-2019-02.005 – GPFV Assurance Mr Morgan introduced the GP Forward View paper, the purpose of which was to provide a formal assurance report to Primary Care Commissioning Committee on the key work-streams within the GP Forward View (GPFV) as follows:-

New Models of Care

Workforce

Extended Access

Workload/High-Impact Actions

IT Mr Morgan referred to the relationship between the assurance paper and the Primary Care Strategy which was to be discussed later on the Agenda. He advised of further developments since the paper had been written around the commissioning of a national training company to run several events to support the retention of GPs, using funding received from NHS England. Interviews for the Physician Associate Internship Scheme were scheduled to take place during week commencing 11 February 2019. The role of Physician Associate is one of the new roles relating to

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workforce and is part of the new scheme going forward. Data relating to the first three months of the Extended Access scheme was being analysed and Mr Morgan will update the April meeting on findings relating to trends, etc. ACTION: Mr Morgan to update the April meeting regarding the information supplied by the first three months data relating to GP Extended Access. Mr Timmis expressed concern regarding the tight timetable for some initiatives. Mrs Wilde agreed that there was a lot of work going on and at present the team were confident of delivery. The Committee confirmed that they were assured on the delivery and mechanisms of GP Forward View and would accept a further update at the next meeting. PCCC-2019-02.006 – National GP Retention Scheme – Proposed Decision Making Guidelines Mr Morgan presented the paper around the National GP retention scheme and asked the Committee to support the recommendations around the decision-making process and the potential financial impact on the CCG. The paper also proposed a set of criteria to enable the PCCC to make decisions on individual applications to the Scheme from GPs. Discussion took place regarding the potential cost of the scheme, which the CCG is required to fund. Mr Morgan outlined proposals to reduce this financial risk by introducing guidelines. Discussion took place regarding the criteria contained in Mr Morgan’s report and Mrs Skidmore stated that she did not believe that criteria number 2 in the report was appropriate. She believed that the criteria for funding should be linked to the Committee considering the impact of taking the decision. Mrs Skidmore believed that the criteria should be amended to state:- “It is incumbent on the Committee to judge whether this need for spend is prioritised over other needs that the CCG may have”. Mrs Woods advised that Committees from other CCGs had considered establishing a budget line within the financial planning of the Primary Care budget to identify whether there is financial allocation that can support a number of applications, and suggested that the CCG may wish to set a timescale by which applications must be received. Discussion followed regarding budgets and timelines for the scheme and Mrs Skidmore confirmed that a non-recurrent budget would be set but separate funding would not be identified. The Committee noted and accepted the criteria contained within Mr Morgan’s report. ACTION: Mrs Woods to share with the Committee HEE and NHS England information relating to the decision-making timeline. PCCC-2019-02.007 – Finance Update Mrs Skidmore reported on the Month 9 financial position for 2018/19, stating that the CCG is still a small percentage below total allocation in terms of forecast. She reminded the Committee of the financial pressures faced by the CCG. Every line of spend within CCG budgets is currently being scrutinised and she anticipated that the forecast for Month 10 would increase the underspend by approximately £200k. This should create a 1% or less variance against a £43m budget. Mrs Skidmore referred to bids and applications relating to the GP Retention Scheme which were currently being processed, and Mrs Wilde confirmed that bids currently in the process were not subject to criteria guidelines as these did not become applicable until 18 February 2019. Two applications were currently in process which will collectively cost the CCG £25k per annum, and Mrs Wilde asked the Committee to support those two applications in line with previous decisions made.

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The Committee approved the two applications referred to by Mrs Wilde. Mrs Skidmore referred to the 2019/20 budget, stating that at the point her paper was written she was awaiting information relating to the new GP contract. This information has now been received and the Finance team are currently considering the implications for the 2019/20 budget. After discussion with the Finance team at NHS England, Mrs Skidmore requested that an Extra-ordinary Primary Care Commissioning Committee take place in March in order to consider the budget and agree sign off. Mrs Alamanos referred to the APMS line in the budget, stating that the funding will continue for another 5 years. However the funding level may change subsequent to the procurement of a new contract. ACTION: Mrs Skidmore and Mrs Wilde to liaise regarding a process to balance the quality needs and the financial requirements of the budget and feed back to the March Committee. PCCC-2019-02.008 – Risk Register Mr Ellis advised the Committee of two new risks – procurement of the APMS contract to replace Whitehall Medical Practice, and the risk of being unable to find a suitable provider. Mr Timmis suggested that when the Register was reviewed, the source of assurance should be updated to reflect exactly what that source of assurance is. Primary Care Commissioning Committee itself is not a source of assurance. Revisions because of the Long Term Plan will also form part of the update. The Committee accepted the risk and mitigations. PCCC-2019-02.009 – Shifnal Premises Development Business Case Mrs Alamanos introduced the paper relating to the Shifnal Premises Development Business Case which had been developed as a result of joint discussions with the CCG, and highlighted key issues and points to note as follows:-

Redevelopment of the Shifnal premises was considered to be the second priority for the CCG

in its submission to NHSE under ETTF. The development subsequently received approval for

funding.

The current premises need significant development to ensure they are compliant and there

would remain issues relating to capacity and accessibility.

The financial impact on the CCG budgets has been assessed and equates to a significant

increase (£154,000 plus an increase in rates) on an already pressurised CCG budget.

The request for additional one-off costs to be paid to the Practice is not supported by the CCG.

There is time limitation on the availability of ETTF monies allocated to this scheme which

should be considered.

The Business Case does not clarify details of the branch surgery in Priorslee or its current

utilisation / potential to support the development in Shifnal.

The business case does not reflect current national policy around Primary Care at Scale,

Primary Care Networks or full utilisation of how technology and mobile working will impact on

future premises requirements.

There is no information contained within the Business Case on wider evaluation under the One

Public Estate programme of work.

There is no clarity on the ongoing partnership and workforce planning as would be expected

within a full Business Case as this is for a 25 year lease.

The options for Committee to consider were defined in Mrs Alamanos’s report.

Discussion followed regarding the various aspects of the Business Case which Mrs Wilde did not

believe went far enough to enable the Committee to be assured that public money is being

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invested in the right way. She also believed that some of the information the Committee would

expect to have sight of was not outlined in the paper.

The impact of any delay in approval was discussed, and Mrs Woods advised that the project must

be completed by March 2021, i.e. built and occupied. There potentially may be issues around the

land if long delays were experienced.

Discussion followed regarding health and social care issues. Cllr Chapman expressed his

concern relating to planning forward capacity and the additional capacity of the Shifnal GP

Practice. He expressed concerns around One Public Estate and the issues relating to

transformation.

Mr Seymour, Assura Medical, confirmed that the projected start date of December 2019 would

mean completion in December 2020, therefore only a small delay of approximately three months

would be feasible. Given the issues raised by the Committee, Mrs Alamanos and representatives

of the CCG would meet with the Practice and Assura to address the issues and to resubmit the

business case to a future meeting.

ACTION: Mrs Alamanos to provide an update on progress and timescales to the Extra-

ordinary meeting scheduled to take place on 6 March 2019 .

PCCC-2019-02.010 – Communications & Engagement Update

Mrs Harper referred to the key points of her report as follows:-

There had been a diverse range of activity from pro-active engagement campaigns through to re-active communications work around areas such as media inquiries.

The work had been delivered by the CCG’s in-house Communications & Engagement team in conjunction with the Primary Care Team, and strong working links and protocols are now in place.

Going forward, this activity provides a foundation to build on and consequently the Communications & Engagement Plan will be updated pending publication of the Primary Care Strategy and confirmation of the local perspective of the new Long Term Plan.

Mrs Harper advised the Committee that initial meetings had already taken place with the Primary Care team and the Medicines Optimisation team around future planning. Further information is awaited regarding the CCG’s position on the Long Term Plan and also the launch of the Strategic Primary Care Plan. When these are available, the Communications and Engagement Plan will be updated. It is hoped to bring this back to the Committee at a future date. Mr Timmis referred to communication with GP Practices which he had been asked to raise on behalf of Dr Shepherd. Staffing issues in the Communications Team were discussed, as two members of staff had left. Mrs Tilley advised that recruitment was currently taking place for both posts. Discussions were taking place with various members of staff across the organisation to prioritise work, and communication with GP Practices formed part of these discussions. Mrs Harper provided assurance to the Committee that key work is being completed. PCCC-2019-02.011 – Primary Care Working Group

Mrs Stevenson presented her report, the purpose of which was to seek approval from Primary

Care Commissioning Committee for the Primary Care Working Group to be discontinued in its

current format. The key points raised were:

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The Primary Care Working Group was set up before the CCG took on delegated authority for

Primary Care commissioning, and before there was a dedicated Primary Care

team/Directorate in place.

The group was originally set up as a ‘Primary Care Quality Group’. It changed to become a

working group of the Primary Care Commissioning Committee after the CCG took on

delegated authority for Primary Care commissioning.

The agenda has focused on the implementation of the GP Forward View work streams.

However this is now considered ‘business as usual’ and is managed by the Primary Care

team.

The majority of items discussed at Primary Care Working Group are discussed at other

meetings.

The Provider Forum was set up in March 2018 and is a forum where items can be discussed

with a much wider Primary Care audience.

It is proposed that task and finish groups with a specific focus are set up with appropriate

membership, including Practice Manager representation, as and when particular projects are

identified.

The Committee agreed to the discontinuation of the Primary Care Working Group in its current

format.

PCCC-2019-02.012 – Shropshire/Telford & Wrekin Sustainability & Transformation Primary

Care Strategy Planning

Mrs Wilde referred to her pre-circulated report, the purpose of which was:-

To inform Shropshire and Telford & Wrekin CCGs of the Primary Care requirements as

outlined in the NHS Long Term Plan (LTP) published in January 2019.

To gain support for the production and content of a Sustainability and Transformation

Primary Care Strategy in line with the requirements in the LTP and GP Forward View

(GPFV). This is required by NHSE by 1st April 2019.

When the Long Term Plan was issued, it contained a requirement that all STP Primary Care

strategies needed to be refreshed to ensure that they reflected the future needs of primary care.

Mrs Wilde met with Telford & Wrekin CCG and a decision was taken that the strategy should be re-

written rather than upated. However, this creates a timing issue as the strategy must be completed

by 1 April 2019. Communication and engagement will be a key element of the process.

Shropshire CCG was working with Telford & Wrekin CCG to develop the strategy. A final version of

the document will be submitted to the April meeting.

As requested, the Committee:-

Noted the Primary Care requirements as laid out in the NHS Long Term Plan and GP

Forward View

Agreed to the development of a new STP Primary Care Strategy and the proposed content

Agreed to accept the final version of the draft STP Primary Care Strategy by 1st April 2019

for approval at the April Primary Care Commissioning Committee

PCCC-2019-02.013 – NHS England Update

Mrs Woods had no updates to report.

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PCCC-2019-02.014 – Cycle of Business

The Committee noted the information contained within the Cycle of Business.

PCCC-2019-02.015 – Any Other Business

Mrs Wilde referred to the new GP contract guidance that had recently been released and will update

at a future meeting.

Mrs Tilley referred to the Terms of Reference of the Committee, which the CCG had been working to

update. Work had been ongoing to update the CCG’s Constitution, which has now been

completed. However, the CCG has received information that it is now a requirement of the

Constitution that the CCG publishes the Terms of Reference of its statutory Committees. Primary

Care Commissioning Committee is one of those Committees and NHS England have raised several

minor points around formatting and standard wording from the model Terms of Reference which

they felt needed to be amended. Given that the requested amendments did not alter the sentiment

of the Terms of Reference, Mrs Tilley has updated the document and the Terms of Reference have

been published.

PCCC-2019-02.016 – Date of Next Meeting

Mr Timmis confirmed that the next meeting, which will be an ExtraOrdinary meeting, will take place

on Wednesday 6 March 2019.

1

Agenda item: GB-2019-05.081a



Name of Committee:

Quality Committee

Date of Meeting:

27 February 2019

Chair:

Meredith Vivian- Lay Member – Patient & Public Involvement


It was noted that the SaTH Director of Nursing and Midwifery and the Head of Midwifery are

leaving the trust before the end of March and the Deputy Director of Nursing and Midwifery is

leaving in May. This leaves the Trust very much at risk and creates some significant clinical

issues. Formal escalation may be necessary prior to the Safety and Oversight Group meeting.

The letters regarding a number of clinical concerns had been sent again to the SaTH Director of

Nursing and Midwifery and the Medical Director and responses have now been received.

However, the response did not cover the issues of paediatric competencies identified on 13th

September. This was subsequently raised at CQRM and it appeared the clinical executive who

provided the ‘safe today’ report on 13th September was also under the impression that paediatric

competencies had been. This confirmed the CCG Director of Nursing and Quality’s repeated

concerns about receiving assurance from these safe today reports. It was agreed that the

Medical Director would escalate this and other issues to the NHS Improvement Chair of the

Safety and Oversight Group.

Special Educational Needs and Disability (SEND): The Designated Clinical Officer is currently on

Maternity Leave and because of SEND requirements, an interim had been appointed until the

end of March. She is working very closely with the Local Authority and the providers to ensure

that the CCG’s processes are appropriate.

Designated Doctor –Safeguarding Children. The post is being advertised on NHS Jobs with an

extended closing date. However, recruitment to a Consultant Paediatrician post is challenging

and no enquiries had been received which is a risk for the CCG. Dr Ganesh- Consultant

Paediatrician at SCHT continues to cover the role but the CCG is not meeting its statutory

requirements of two sessions per week. The CCG Director of Nursing and Quality had discussed

this with her counterpart at Telford & Wrekin CCG to work jointly to try to increase weekly

sessions to three and NHS England had been advised of the risk.

Patient Voice: It had been agreed that items for Patient Voice would be submitted to Quality

Committee for consideration and would then be submitted to the Governing Body. The

Committee agreed that Patient Voice should be put back onto the Governing Body Agenda

provided the subject matter was appropriate. The Committee discussed Patient Experience and

2

it was agreed that feedback should be requested from patients regarding their engagement

experience.

The Quarterly Infection Prevention & Control Report detailed the performance at Quarter 3

against the 2018/19 healthcare associated infection targets set for Shropshire CCG and local

NHS Trusts and action being taken to improve quality, safety and patient experience in relation

to infection prevention and control. Shrewsbury and Telford Hospital (SaTH) have breached the

national zero tolerance MRSA bacteraemia. In Quarter 3, two further cases were locally

assigned to SaTH as a result of poor blood culture practices contaminating blood samples in

Accident and Emergency Departments. Actions to address this are monitored by the CCG IPC

Lead

Shropshire CCG and SaTH remain on target to achieve their 2018/19 Clostridium difficile

infection targets. However, Robert Jones and Agnes Hunt Hospital and Shropshire Community

Health Trust have breached their year-end target of 1 each by reporting 2 cases each at the end

of Quarter 3. Actions to address this are monitored by the CCG IPC Lead

Looked After Children: The non-delivery of statutory Health Passports remains on the Risk

Register as high. The CCG Director of Nursing & Quality had identified funding to ensure the

backlog can be cleared as a one-off payment and a letter had been sent to SCHT advising of

contractual requirements. Implementation will be monitored at the CQRM. The interim children’s

commissioner is supporting the Designated LAC Nurse with this.

The Young Health Champions project had been awarded a small grant of £5000 to focus the

health care champions work on developing young women’s self-esteem

The Adult Safeguarding Report included updates on

-Prevent Duty Assurance work

-SaTH and safeguarding assurance work in light of the CQC actions and the challenges owing to

outstanding work from SATH

-Updates regarding Safeguarding Adult Reviews

-Briefing regarding the Serious Organised Crime Joint Action Group (SOCJAG)and the

information sharing issue

-Domestic Abuse services updates including the funding support from NHSE non-recurring

monies to Shropshire Domestic Abuse Service

-The new Mental Capacity Amendment Bill and its implications


To receive the summary of the Quality Committee minutes, to note the risks identified and

actions being taken to address these.

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MINUTES OF THE QUALITY COMMITTEE

HELD IN ROOM B, WILLIAM FARR HOUSE

AT 3.00PM ON WEDNESDAY 27 FEBRUARY 2019

Present Mr Meredith Vivian Lay Member – Patient & Public Involvement (Chair) Mr Keith Timmis SCCG Lay Member Dr Julie Davies Director of Performance & Delivery Ms Dawn Clarke Director of Nursing & Quality Dr Jessica Sokolov Medical Director, Shropshire CCG Dr Alan Leaman Secondary Care Consultant Dr Finola Lynch GP Member Ms Lynn Cawley Chief Officer, Healthwatch Shropshire Mrs Chris Billingham Personal Assistant, Minute Taker In Attendance Mr Paul Cooper Head of Adult Safeguarding Mr David Coan Designated Nurse for Children’s Safeguarding Ms Maggie Braun Designated Nurse - LAC Mrs Jane Blay Patient Safety & Quality Co-Ordinator Ms Charlotte Dunn Quality Assurance Officer Ms Jenny Bate Senior Nurse for Primary Care & Nursing Homes and Infection Prevention and Control Nurse Specialist

QC-2019-2.018 (Agenda Item 1) - Apologies Mr Vivian welcomed members and those in attendance to the meeting. Apologies were received from Mrs Sarah Porter and Ms Samantha Bunyan. QC-2019-2.019 (Agenda Item 2) - Members’ Declaration of Interests There were no declarations of interest. QC-2019-2.020 (Agenda Item 3) – Minutes / Actions from Previous Meeting held on 30 January 2019 and Action Log The minutes of the previous meeting held on 30 January 2019 were reviewed and approved. Action Log from 30 January 2019 Members received an update for each item and noted that all actions had been completed or were an Agenda item with the exception of: Item QC-2019-1.013 - Annual Review of Quality Strategy and Delivery Plan The minute should read:- “Ms Clarke has asked the Quality team for their input and the updated Quality Strategy and Delivery Plan will be brought to the March Quality Committee”. Invitations to SaTH representatives to attend Quality Committee Ms Clarke advised the meeting that Ms Deirdre Fowler was leaving before the end of March, the Deputy Director of Nursing is also leaving and the Head of Midwifery had also resigned which leaves the Trust very much at risk and creates some significant clinical issues. ACTION: Mrs Billingham to ask Mr Peter Jeffries to attend the March Committee meeting. Ms Clarke expressed the view that formal escalation of the CCG’s concerns regarding the resignations of senior staff at SaTH may be necessary.

Governing Body – 5.08.19

Agenda Item – GB-2019-05.81

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Learning Disability Health Checks An update will be brought to the next meeting. ACTION: Ms Clarke to bring an update on health checks to the March meeting. Designated Doctor – Looked After Children The post is now being advertised on NHS Jobs with an extended closing date. However, recruitment to a Consultant Paediatrician post is challenging and no enquiries had been received, which is a risk for the CCG. Dr Ganesh continues to cover the role, but the CCG is not meeting its statutory requirements of two sessions per week. Ms Clarke had discussed this with her counterpart at Telford & Wrekin CCG to work jointly to try to increase weekly sessions to three, but no funding is available at T&W to support an increase in the number of sessions. ACTION: Ms Clarke to update the next meeting regarding progress on the recruitment of a Designated Doctor for Childrens Safeguarding. Provider Exception Report 0-25 Medicines Audit Mr Coan attended the SSSFT 0-25 CRB/CQRM meeting on 22 February 2019. Feedback at CQRM was that it is progressing, but there are still issues. The Recovery Action Plan is being complied with. Concerns are no longer being raised by GPs and complaints are less frequent than before. Advanced Care Home Framework Good progress is being made. ACTION: Ms Clarke to arrange for Ms Hassall to update the March Quality Committee on the Advanced Care Home Framework. Collation of Letters Sent by the CCG to SaTH Ms Clarke had forwarded the letters again to Ms Fowler and Mr Borman and a response has now been received. However, the letter did not cover the issues of paediatric competencies on 13

th September. This was

subsequently raised at CQRM and it appeared the clinical executive who provided the safe today report on 13th

September was also under the impression that paediatric competencies had been met. Dr Davies provided an update on the End of Life pathway and issues relating to flags around the 111 system and Shropdoc records. No further issues have been experienced that the CCG are aware of. Dr Davies also updated the meeting regarding the performance of West Midlands Ambulance Service. Because of the significant increase in ambulance conveyancing experienced this winter, a new group has been set up to specifically target the reason for that increase in demand. Initial analysis shows an increase in 999 calls. Ms Clarke confirmed that she had now received a copy of the three-way response to the Coroner’s letter. ACTION: Dr Davies to ask Ms Pyrah to update the March Committee with further details of the increase in demand for ambulance conveyancing. Special Educational Needs and Disability The Designated Clinical Officer is currently on Maternity Leave and, because of SEND requirements, an interim had been appointed until the end of March. She is working very closely with the Local Authority and the providers to ensure that the CCG’s processes are appropriate. Transforming Care Programme Including LEDER Ms Clarke advised that there are currently 19 patients in the Shropshire TCP. The TCP will not meet the end of March deadline as the current situation is very challenging, for example some patients are currently in active treatment and cannot be discharged. Adult & Childrens Safeguarding Policies and LAC Report Nationally, the situation is very challenging. A situation exists currently with Health Passports, details of which Ms Braun has included in her report. The situation has been routinely raised at Quality Surveillance Group. Dr Leaman asked how the small children’s homes are monitored. This sits with Ofsted and the Local Authority. ACTION: Ms Clarke to write to the Chair of the Corporate Parenting Panel asking for site visits by voluntary agencies to be considered. Agenda item for discussion at a future meeting.

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Annual Review of Quality Strategy and Delivery Plan ACTION: Ms Clarke to bring the updated plan to the March meeting. Points to Escalate to CCG Board Dr Sokolov had enlisted the assistance of Healthwatch to move SaTH up the Agenda of the NHS Improvement meeting. QC-2019-2.021 (Agenda Item 4) – West Midlands Quality Review NHS England has requested that WMQRS review the quality management arrangements at both CCGs to see if there could be greater efficiencies made across both teams. Ms Clarke and Mr Vivian thanked everyone involved in the review for their hard work and efforts. Feedback received was generally positive. QC-2019-2.022 (Agenda Item 5) – Quality Strategy & Delivery Plan Ms Clarke advised that all of the Quality team have reviewed their objectives for the forthcoming year which now need to be amalgamated into one delivery plan. The main focus is to align Commissioning Leads and other Leads to ensure delivery of strategies. QC-2019-2.023 (Agenda Item 6) – Provider Exception Report The purpose of the pre-circulated report was to provide assurance to the Governing Body that processes are in place to monitor quality indicators, and escalate and ensure remedial action is in place where poor performance is identified. Appendices to the report were:- Appendix 4.1 – SaTH CQC 28 Day Response Appendix 4.2 – NHS England Acute Dashboard Appendix 4.3 – NHS England Mental Health Dashboard Appendix 4.4 – Monthly Serious Incident Report Appendix 4.5 – SaTH Cancer Breaches The Committee noted the key issues. Ms Clarke referred to Appendix 4.1 which was SaTH’s response to CQC which she felt needed further consideration. Any comments regarding the content, deliverables and factual accuracies should be fed back to Ms Clarke who will collate a response for sign-off by Dr Freeman. ACTION: All Committee members to feed back to Ms Clarke their comments regarding SaTH’s response to CQC. Discussion followed regarding specialties that were particularly pressured, and in particular cancer waits. Dr Davies advised that this is part of the recovery plan for cancer. There are challenges, but with structured planning these can be overcome. However, concerns existed regarding Urology. SaTH had written to NHS Improvement regarding these and have entered into a Memorandum of Understanding with University Hospital North Midlands to try and develop a partnership arrangement. No response has yet been received from NHS Improvement but Dr Davies will monitor the situation. Discussion followed regarding recent publicity in the media regarding Shropdoc. Dr Davies advised that an urgent meeting was being arranged with both the Commissioners, Shropcom and Shropdoc to understand the issues, cross reference them against demand, and seek assurance on behalf of both CCGs. QC-2019-2.024 (Agenda Item 7) – Safeguarding Quarterly Reports Adult Safeguarding Mr Cooper reviewed his report to the Committee, key points of which were:-

Prevent Duty Assurance work

SaTH and safeguarding assurance work in light of the CQC actions and the challenges owing to outstanding work from SATH

Updates regarding Safeguarding Adult Reviews

Briefing regarding the Serious Organised Crime Joint Action Group (SOCJAG)and the information sharing issue

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Domestic Abuse services updates including the funding support from NHSE non-recurring monies to Shropshire Domestic Abuse Service

The new Mental Capacity Amendment Bill and its implications Mr Cooper wished to highlight SOCJAG (Serious Organised Crime Joint Action Group) which dealt very specifically with County lines and “cuckoo-ing” in Shropshire. “County lines” is when organized crime gangs import drugs into an area using dedicated telephone lines. They utilize people – usually young and vulnerable – to sell drugs for them in that area. There is a related concept of “cuckoo-ing” whereby people who are vulnerable have their homes taken over for illicit purposes. Some very specific work has been done with the police about publicizing this form of exploitation. The police have commended the Community Trust for the quality of information shared. Mr Cooper referred to the Mental Capacity Amendment Bill, the third reading of which took place on 12 February 2019. This will have significant implications for the Community Trust which, under the new scheme, will have responsibility for the deprivation of liberty and the assessments that are required going forward. Two policies had been submitted for Quality Committee approval – the Mental Capacity Act Policy and the Deprivation of Liberty Policy. Both of these policies are multi-agency and they have been written by the Multi Agency Operational Group of which Mr Cooper is the Chair. The policies were written in 2015 and had been extensively revised over the last three months. The Committee approved the Mental Capacity Act Policy and the Deprivation of Liberty Policy submitted by Mr Cooper. Childrens Safeguarding Mr Coan reviewed his Safeguarding report, the purpose of which was to update the Committee regarding the current safeguarding and Looked After Children (LAC) position in Shropshire. Key points to note were:-

Proposed changes to the Safeguarding core groups in Shropshire

The Young Health Champions project had been awarded a small grant of £5000 to focus the health care champions work on developing young women’s self-esteem

The non-delivery of statutory Health Passports remains on the Risk Register as high. The Director of Nursing & Quality had confirmed funding to ensure the backlog can be cleared as a one-off payment and a letter had been sent to SCHT advising of contractual requirements. Implementation will be monitored at the CQRM. The interim children’s commissioner is supporting Maggie Braun- Designated LAC Nurse with this.

Shropshire Local Authority are currently undertaking a service review of the Public Health Nursing Contract

Discussion took place regarding changes to the Safeguarding core groups. Mr Coan advised that one of the key challenges will be reporting and providing reports to parents prior to a meeting. GPs may be required to attend case conferences, and this may be a challenge for some. Mr Coan referred to a Serious Case Review meeting which had taken place earlier involving a child with learning needs and disabilities. The Safeguarding team intended to review the case and “lessons learned”. However, an independent author will be required who cannot be anyone involved in the case. ACTION: Dr Sokolov and Ms Clarke will discuss the subject of an independent author for the Serious Case Review. Ms Cawley referred to Young Health Champions and the possibility of joint working between the two organisations. Mr Coan will forward details of the Lead employed by the Youth Service to Ms Cawley. ACTION: Mr Coan to forward to Ms Cawley contact details. The Safeguarding system in the SaTH Maternity Unit was discussed, including the interface between separate reporting systems. Mr Vivian advised that the Committee must question if a patient may be lost to the two operating systems. Mr Coan assured the Committee that the same system is used nationally and there is no reason why a patient would be lost to either system.

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QC-2019-2.025 (Agenda Item 8) – Infection Prevention & Control Quarterly Report In Mrs Kidson’s absence, Ms Bate reviewed the Quarterly Infection Prevention & Control Report, the purpose of which was to detail the performance at Quarter 3 against the 2018/19 healthcare associated infection targets set for Shropshire CCG and local NHS Trusts, and action being taken to improve quality, safety and patient experience in relation to infection prevention and control. Key points to note were as follows:-

Shrewsbury and Telford Hospital (SaTH) have breached the national zero tolerance MRSA bacteraemia. In Quarter 3 two further cases were locally assigned to them as a result of poor blood culture practices contaminating blood samples in Accident and Emergency Departments.

Shropshire CCG and SaTH remain on target to achieve their 2018/19 Clostridium difficile infection targets. However, Robert Jones and Agnes Hunt Hospital and Shropshire Community Health Trust have breached their year-end target of 1 each by reporting 2 cases each at the end of Quarter 3.

The national requirement to focus on reducing Escherichia coli (E.coli) bacteraemias in 2018/19 continues to be supported by Quality Premium for CCGs. At the end of Quarter 3 Shropshire CCG has breached the national ambition by reporting 212 cases against a year-end target of no more than 205 cases.

At the end of December 2018 out of the 169 staff working for Shropshire CCG, 69 had received their flu vaccination from Occupational Health service, giving an uptake rate of 41%. However, this does not take account of those staff members who may be in an ‘at risk group’ and have received their vaccination from their GP.

At CQRM the previous day, SaTH reported that initially their NHS Improvement Recovery Plan was completed as they were on target. However, they are now required to submit a further one as the improvement was not maintained. At the same meeting, the Chief Pharmacist of SaTH advised that they are failing again on their Antimicrobial Stewardship. Ms Clarke advised she had written to the Medical and Nurse Director following the CQRM to raise this as a concern. QC-2019-2.026 (Agenda Item 9) - Healthwatch At the previous meeting it was acknowledged that the CCG was attempting to manage a backlog of complaints. Ms Cawley requested an update on progress as many of the people who contacted Healthwatch felt that there had been bad communication. Ms Clarke replied that provider issues are picked up through the CQRM meetings but with minimal detail. Having taken back responsibility for CHC, she was aware that a number of complaints had not been addressed and these are currently being dealt with. Ms Clarke had appointed a new Interim Clinical Lead to support. CCG complaints management sits with the Director of Corporate Affairs not with herself and Mrs Tilley needs to have an opportunity to respond directly. Ms Cawley had written to Mr Simon Wright- CEO at SaTH about stroke and had received a reply which she would like to share for validation of the information contained therein. ACTION: Mr Vivian will pick up the issue of complaints directly with Mrs Tilley. ACTION: Ms Cawley to share the letter received from Mr Wright regarding stroke with Ms Clarke for validation of information. Healthwatch Shropshire are carrying out a piece of work for Healthwatch England on Perinatal Mental Health. Ms Cawley will be meeting with Mrs Jo Banks, SaTH Women & Childrens Care Group Director, regarding that piece of work. The next major piece of work being undertaken by Healthwatch Shropshire is public engagement around STP and the NHS Long Term Plan, working with Healthwatch Telford & Wrekin in order to have a co-ordinated approach across the area. This will commence on 1 March 2019.

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QC-2019-2.027 (Agenda Item 10) – Patient Voice It had been agreed that items for Patient Voice would be submitted to Quality Committee for consideration and would then be submitted to the Governing Body. The Committee agreed that Patient Voice should be put back onto the Governing Body Agenda, provided the subject matter was appropriate. The Committee discussed Patient Experience and it was agreed that feedback should be requested from patients regarding their engagement experience. Ms Cawley agreed to forward any relevant feedback received by Healthwatch to Mrs Blay. Mrs Blay suggested that the first patient story should be a film called “Roy’s Story”, regarding the impact of the frailty initiative to be placed on the May Agenda. Mrs Blay will send the film to Ms Harper who will share with Dr Povey for approval. ACTION: Mrs Blay and Mr Vivian to discuss Patient Voice and Patient Experience outside this meeting. Mrs Blay to forward “Roy’s Story” to Ms Harper for approval by Dr Povey. Ms Cawley to forward any relevant feedback received by Healthwatch to Mrs Blay. QC-2019-2.028 (Agenda Item 11) – Points to Escalate to CCG Board Items to escalate to the Governing Body were:-

Senior Nurse Leadership leaving SaTH QC-2019-2.029 (Agenda Item 12) – Any Other Business Terms of Reference The amended Terms of Reference have now been approved and will be submitted to the March Governing Body for sign off. Executive Representation Ms Clarke reminded the Committee of her forthcoming departure from the organisation in three months’ time. There is an expectation that an Executive Lead will be present at Safeguarding Boards, and also a requirement for Executive level input to certain meetings and decisions. She asked the Committee to consider requirements going forward. ACTION: Mr Vivian will discuss future requirements and arrangements for Executive Safeguarding representation with Dr Freeman and Dr Povey. Date of Next Meeting The date of the next meeting is Thursday 28 March 2019 at 2.00 p.m. in Room K2, William Farr House. Please note the change of date, time and meeting room.

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Agenda item: GB-2019-05.081b



Name of Committee:

Quality Committee

Date of Meeting:

28 March 2019

Chair:

Meredith Vivian- Lay Member – Patient & Public Involvement


The draft West Midland Quality Review Services (WMQRS) report on how the CCG governs

quality had been received for the CCG to review factual accuracy prior to the final report being

received. The review stated that Shropshire CCG had been reviewed by WMQRS in July 2017

(report published September 2017). Reviewers were impressed with the progress that the CCG

had made in addressing issues identified at the time of the previous visit.’ The 2019-2020

Quality Strategy and Delivery Plan to be brought to Quality Committee in April will include the

actions taken to address the minor recommendation made.

A Never Event was reported by Shrewsbury and Telford Hospital Trust. The 72 hour report

identified that policy had been followed and no harm had come to the patient. However this

remains under review

Continual shortages of nursing staff at RSH were discussed, and the impact of this on patient

care and staff training and development. The Committee requested additional assurance from

the workforce stream that specific issues are being addressed

A letter had been sent to Simon Wright-CEO at SaTH by Mrs Chris Morris- Executive Nurse at

Telford & Wrekin CCG in her capacity as Senior Responsible Officer for the Local Maternity

System in which she requested assurance about SaTH’s engagement with the Local Maternity

System process. There are two areas where no progress is being made. The first is continuity of

carer to ensure safer care based on a relationship of mutual trust and respect between women

and their midwives, which is a key part of Better Births, and Information Technology issues

impacting on communication and safe care.

Special Education Needs and Disability (SEND) is a statutory requirement under the Children

and Families Act 2014. It requires local partners to work together to deliver a coordinated and

simplified offer to children and young people (aged 0 – 25).The CCG is working with the Local

Authority to prepare for a SEND local area inspection but more importantly to strengthen existing

processes. The Self Evaluation Framework has been completed and an audit of CCG

requirements has also been completed which has highlighted several areas of compliance and

areas for improvement. Action is being a taken to address the areas for improvement. Clear

pathways are being developed to support better identification of trends around behavioural

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challenges and the children’s emotional health and wellbeing.

Child Death Overview Panel (CDOP): The Child Death Overview Panel is a statutory

requirement which feeds into Safeguarding Boards. Nationally some CDOPs are being

combined to ensure population mass supports learning and Shropshire, Telford & Wrekin

Safeguarding Boards have been in discussion with Herefordshire CCG, Worcestershire CCG,

and West Mercia Police and the Local Authorities and Public Health with a view to creating a

joint CDOP. It has been agreed that Herefordshire and Worcestershire will work together to

improve their current situation, and the Shropshire and Telford & Wrekin CDOP will continue as

a separate CDOP but with a view to merging within 6-12 months. A further call is planned

Enhanced Care Home Framework: Regular bi-monthly meetings with NHS England, Telford and

Wrekin CCG and Shropshire CCG are in place to progress actions and consider merging the

Care Home Framework. Shropshire CCG and Telford CCG are working collaboratively to

implement the programme in line with NHSE Sustainability and Transformation Plan (STP)

approach. Key issues to note within the framework are the roll out of the ‘Red Bag’ scheme, and

that currently 15 Care Homes now have nhs.net email accounts. A focussed piece of work is

being led by Shropshire Partners in Care to support the roll out of these further.

The Red Bag Scheme which Telford & Wrekin CCG had been piloting since May 2018 and

which Shropshire CCG are about to roll out in April will work in conjunction with the Care Home

Advance Scheme where residents are assessed within a Care Home by a GP with a view to

future planning. Care Homes who have signed up to the Care Home Advance Scheme are

required to write a Care Plan for their patients. The number of Care Plans in place is monitored

by the Primary Care team

Continuing Healthcare (CHC) and Complex Care: The report outlines planned developments

within the service over the next three months. Key points to note were:-

-The introduction and setting up of a weekly reporting tool in line with identified Key Performance

Indicators across the service to allow for close performance monitoring. The process for

ratification had been implemented immediately to avoid delays for new referrals. The backlog is

being addressed urgently.

-The significant need to develop the Personal Health Budgets process within the Complex Care

Team in alignment with NHS England requirements of between 320 and 450 by March 2020.

Shropshire CCG currently have 24 patients funded by a Personal Health Budget so this is a high

risk area and the CCG is part of a pilot mentoring scheme with NHS England to support

improved delivery.

-A number of substantive posts had not been recruited to compounding the issues of capacity in

the team. Six posts are currently out to advert, one of which has now been filled. A high number

of Agency staff is being used. A duty desk nurse is being appointed to enable the band 7 Mental

Health and Learning Disability nurses to focus on Complex Care issues rather than Continuing

Health Care (CHC) and for the band 7 CHC nurses to focus on supervising and monitoring of

processes rather than acting down as they are currently having to.


To receive the summary of the Quality Committee minutes, to note the risks identified and

actions being taken to address these.

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MINUTES OF THE QUALITY COMMITTEE

HELD IN ROOM B, WILLIAM FARR HOUSE

AT 2.00PM ON THURSDAY 28 MARCH 2019

Present Mr Meredith Vivian Lay Member – Patient & Public Involvement (Chair) Mr Keith Timmis SCCG Lay Member Dr Julie Davies Director of Performance & Delivery Ms Dawn Clarke Director of Nursing & Quality (by telephone) Dr Jessica Sokolov Medical Director, Shropshire CCG Dr Alan Leaman Secondary Care Consultant Mrs Sarah Porter Lay Member for Transformation Ms Samantha Bunyan Head of Quality Jilly Hassall Quality Nurse for Primary Care & Nursing Homes (on behalf of Mrs Tanya Kidson) Mrs Chris Billingham Personal Assistant; Minute Taker

QC-2019-3.031 (Agenda Item 1) - Apologies Mr Vivian welcomed members and those in attendance to the meeting. Apologies were received from Dr Finola Lynch and Ms Lynn Cawley. QC-2019-3.032 (Agenda Item 2) - Members’ Declaration of Interests There were no declarations of interest. QC-2019-2.020 (Agenda Item 3) – Minutes / Actions from Previous Meeting held on 27 February 2019 and Action Log The minutes of the previous meeting held on 27 February 2019 were reviewed and approved, provided the following amendments are noted:- Page 2 – Adult & Childrens Safeguarding Policies and LAC Report Reference to Dr AL should be written in full, i.e. Dr Alan Leaman. Page 3 – West Midlands Quality Review This paragraph should be amended to read:- “Following Autumn 2018, the regulators were concerned that there were issues relating to how the CCG managed incidents that allowed the situation within SaTH to escalate and they were seeking assurance of processes in place as well as how the two CCG Quality teams could work more effectively together. The review had taken place last week.” This to read: ‘NHS England has requested WMQRS review the quality management arrangements at both CCGs to see if there could be greater efficiencies made across both teams’ Matters Arising Safeguarding Dr Leaman referred to the Safeguarding Quarterly report and referred to his questions at the previous Committee meeting regarding the safeguarding system used by the Maternity Unit at SaTH. At that meeting, the Committee were assured that there was not a problem with the interface between the Maternity system and the main hospital system. Following the meeting, Dr Leaman had phoned SaTH and found otherwise. Dr Leaman did not believe that it was correct for the Committee to be assured as the Maternity Unit system is self-contained and does not communicate with the main hospital system used by A&E. Discussion took place as to who was responsible for ensuring that the safeguarding procedures at SaTH are appropriate and rigorous. The Executive Lead for safeguarding at SaTH is the Director of Nursing, with whom ultimate responsibility would rest.

Governing Body – 5.08.19

Agenda Item – GB-2019-05.81

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Dr Leaman requested that the CCG suggests to the Trust that where special concern exists for Maternity patients, those patients should be added manually each week to the main SaTH safeguarding system. ACTION: Ms Clarke to speak with Mr Coan to formally raise this safeguarding issue with the Trust and Ms Clarke to contact the Director of Nursing and Midwifery at the trust. The meeting reviewed the Action Tracker as follows:- QC-2018-10.109:

Mr Trenchard had been invited to attend the Quality Committee on several occasions but was unable to accept any of the invitations. He is now taking up another role as STP Lead for Mental Health & Learning Disabilities. An interim has been recruited to cover the role after Mr Trenchard leaves, and Dr Davies has extended the contract by six months until longer term requirements are established. Cathy Davies MH Commissioner to be invited.

Mrs Billingham will extend an invitation to Mr Peter Jeffries to attend the April Quality Committee.

Learning Disability Health Checks will be raised as a risk at Executive Team as we are without Learning Disability Commissioners. There is no plan in place and Ms Clarke will submit a paper to Exec Team.

Designated Doctor LAC will be discussed as an Agenda item.

QC-2018-11.123: The Advanced Care Home Framework will be discussed as an Agenda item. QC-2018-12.137: Increased Demand for Ambulance Conveyancing: The trend in A&E attendances is not being exacerbated by the shift to NHS 111. Treat at Scene has dropped and attempts are being made to understand why. Dr Davies will provide a report to Finance & Performance Committee on 3 April 2019. QC-2019-01.008: Adult & Childrens Safeguarding Policies and LAC Report: Ms Clarke has written to Karen Bradshaw, Chair of the Corporate Parenting Panel to ask if the CCG can work with the Local Authority on children’s home inspections. The meeting discussed private children’s homes and how CCGs and Local Authorities are made aware that a child is in that home. Ms Clarke advised that this is a national issue which is not straightforward as on many occasions the Local Authority or CCG are not always made aware by the placing Authority. Often the CCG will not be aware until the child is in the Emergency Department in crises. This is a challenge nationally also. ACTION: Ms Clarke to update the Committee in writing as soon as Ms Bradshaw’s response to the CCG’s letter is received. QC-2019-02.026: Complaints: Mrs Tilley is in discussions to see if systems around Complaints can be reviewed and done differently. This was discussed at Executive Team on Monday 1 April and there was a suggestion that a colleague from the Quality Team should assist with complaints for three weeks to help with the backlog. Discussions are taking place with the individual but the impact on the Quality Team must be acknowledged. QC-2019-02.027: Ms Cawley has shared the letter received from Mr Wright regarding Stroke with Ms Clarke. It has also been forwarded to Dr Davies as most of the issues were about commissioning. A Stroke visit was carried out several weeks ago and a letter has been written to Ms Deirdre Fowler identifying several issues. Ms Clarke awaits a response to the findings. QC-2019-02.027: Patient Voice: Discussion took place regarding Patient Voice at the Governing Body. Bearing in mind staff capacity required to perform the research with patients regarding their stories, this will be revisited at a future date. ACTION: As requested by Mr Vivian, Mrs Billingham will send the Quality Committee Terms of Reference to Mrs Stackhouse for approval at the next Governing Body. Resignation of Director of Nursing & Quality

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Mr Vivian wished to discuss arrangements to be put in place when Ms Clarke leaves the organisation in May, and in particular the issue of Executive Lead for those areas for which the CCG has statutory responsibilities. ACTION: Ms Clarke to discuss with the Accountable Officer arrangements to be put in place to prepare for her departure from the organisation in May. Dr Julie Davies joined the meeting at 2.40 p.m. QC-2019-03.034 – Revised Quality Strategy and Delivery Plan for 2019-20 Ms Clarke advised the Committee that she was waiting for the West Midlands Quality Review report in order to consider the recommendations before bringing the revised Quality Strategy and Delivery Plan for 2019-20 to the Committee. The Quality Strategy and Delivery Plan will be brought to the April meeting and will include any recommendations made as a result of the West Midlands Quality Review. Overall, the West Midlands report was positive and showed a journey of improvement by the CCG. Ms Clarke thanked everyone involved for their engagement and commitment to making those changes. ACTION: Ms Clarke requested that Committee members advise her of inaccuracies within the West Midlands report, e.g. job titles, typing errors, etc. and she will incorporate them into a feedback response. Ms Clarke to bring the revised Quality Strategy and Delivery Plan to the April Committee meeting. QC-2019-03.035 – Provider Exception Report The purpose of the report was to provide assurance to the Governing Body that the processes are in place to monitor quality indicators, and escalate and ensure remedial action is in place where poor performance is identified. Ms Bunyan reviewed key points of the report, which were:-

There are concerns regarding the forthcoming senior level vacancies at Shropshire and Telford Hospitals and the impact this will have on leadership and quality of services provided. These include a Director of Nursing, Associate Director of Nursing, and Head of Midwifery & Children’s Services. Ms Clarke advised that a new Medical Director had been appointed, and interim staff will be appointed to the other senior positions.

On 4 March 2019, the BBC reported signage across doors at the Princess Royal Hospital Emergency Department advising that the department was closed to ambulances. This event was discussed at length with the Director of Nursing at SaTH who confirmed that this was unprecedented, done without management knowledge, and would not happen again.

NHS England performance team had raised concerns that the process of reporting 12 hour trolley breaches is still not functioning properly. This has been escalated at the weekly Safe Today conference call to the Trust’s Medical and Nursing Directors, at CQRM and at the Safety Oversight and Assurance Group.

Large numbers of the Maternity workforce remain off sick with work related stress.

A Never Event was reported by Shrewsbury and Telford Hospital Trust. The 72 hour report identified that policy had been followed and no harm had come to the patient.

Discussion took place as follows regarding the main NHS Provider contracts:- SaTH Continual shortages of nursing staff at RSH were discussed, and the impact of this on patient care and staff training and development. The Committee would like to receive assurance from the workforce stream that specific issues are being addressed. Mr Timmis had been copied into a letter written to Simon Wright by Mrs Morris in her capacity as SRO for the local maternity system in which she requested assurance about SaTH’s engagement with the LMS process. Mrs

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Morris wished to bring to Mr Wright’s attention two areas where no progress is being made - continuity of care, which is a key part of better births, and IT issues. Mr Vivian referred to Paragraph 6 of Ms Bunyan’s report which stated that “The Trust Medical Director has met with ED Consultants to re-emphasise the importance of improving processes”. He requested information as to what is going to be done to improve processes, how it will be done, when, and by whom. Dr Davies advised that that this was discussed at a High Impact Workshop which took place in March and will be monitored at a follow on workshop in April. Committee members requested an explanation of a condition being “High Risk” in a future report ACTION: Dr Davies to send Ms Bunyan the template used by the High Impact Workshops. Ms Bunyan will use the template to feed back her input into the improvement process. Sam Bunyan to include explanation of a condition being “High Risk” in a future exception report- May 2019 Mr Coan joined the meeting at 3.00 p.m. Shropcom The meeting discussed potential issues with Shropdoc the Finance & Performance Committee had agreed would be reported under Shropshire Community Health Trust going forward as they are the contracted body. Mr Vivian referred to Paragraph 24 of the report which referred to Looked After Children and funding for Health Passports. Ms Clarke stated that Shropshire Community Health Trust have been advised of the funding that the CCG are able to provide and expressed her disappointment that the service had not been provided and costings were to be finalized later. Mr Coan has met with Commissioning colleagues regarding the potential challenge of Looked After Children within the SCHT. Plans are being devised to ensure that this work is carried out. ACTION: Ms Clarke to obtain an update on the latest position on Health Passports from Ms Malcolm and update Mr Vivian as to the outcome. Robert Jones Agnes Hunt Particular issues existed around spinal which were resolved at a meeting last week. Dr Davies has requested a flow diagram of referral pathways which will be taken to Clinical Commissioning Committee for approval. Shropdoc A review is currently being carried out, as the basis upon which Shropdoc placed their bid was flawed. The results of the review will help inform future procurement. Serious Incident Reporting Discussion took place regarding high numbers of unexpected deaths at MPFT – Paragraph 31 of the report. Ms Bunyan has asked MPFT’s Head of Quality Contract Standards to provide their action plan to improve these figures. The Appendices to the report were discussed and Dr Leaman requested that the graphs be improved to include data before 2017 in order to identify trends. ACTION: Ms Bunyan will update the Committee when the requested action plan is received from MPFT. Ms Bunyan will liaise with CSU to discuss improvements to the graphs and data. QC-2019-03.036 – Special Educational Needs and Disabilities The purpose of the report was to provide the Committee with an update on the implementation of SEND and to seek approval of the recommendations in preparation for a potential Ofsted / CQC inspection. Special Education Needs and Disability (SEND) is a statutory requirement under the Children and Families Act 2014. It requires local partners to work together to deliver a coordinated and simplified offer to children and young people (aged 0 – 25). The CCG is working with the Local Authority to prepare for a SEND local area inspection. The Self Evaluation Framework has been completed and an audit of CCG requirements has also been completed which has highlighted several areas of compliance and areas for improvement. Action is being a taken to address the areas for improvement.

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Clear pathways need to be developed to support better identification of trends around behavioural challenges and the children’s emotional health and wellbeing. Discussion followed regarding staffing challenges. Ms Clarke is the Executive Lead for SEND and a key issue will be to identify a replacement from within the Executive Team to take over this responsibility after her departure from the organization in May if an ongoing solution was not identified. ACTION: Mr Coan to prepare a delivery plan and timescales to update key areas in preparation for the SEND Ofsted / CQC inspection. QC-2019-03.037 – Joint Targeted Area Inspection (JTAI) Action Plan and Designated Doctor Update The purpose of Mr Coan’s report was:-

To remind the Quality committee of the CCG’s statutory responsibility around ensuring both a Designated Doctor and Named GP are in place. It should be noted that the Named GP and Designated professional are distinct roles and as such must be separate post holders.

To provide an update on the advertised position for the Designated Doctor role.

To give an update on the ongoing work following the very successful Joint Targeted Area Inspection (JTAI) and the draft action plan. The Committee discussed the challenges around recruitment of a Designated Doctor. The CCG is also attempting to recruit a Named GP which leaves the CCG very vulnerable as, from a professional point of view, there is currently no GP support. Dr Ganesh, the current Designated Doctor, has volunteered to continue to provide cover in an emergency, but not on a regular day to day basis. Ms Clarke has updated NHS England and advised them of how challenging recruitment to this post is proving to be. Ms Clarke has also discussed possible options with Chris Morris at Telford & Wrekin CCG. The Named Doctor for Safeguarding is currently Dr Sokolov, who is frequently unable to meet the demands that the role makes on her time. Dr Sokolov suggested that Dr Luen Wong, the Named Doctor for Safeguarding at Telford, may be happy to cover the role for Shropshire CCG also. However, consideration must be given to funding a Safeguarding Doctor as Ms Clarke had no budget available to do so. ACTION: Dr Leaman to provide Dr Sokolov with the contact details of an ex-colleague who may be interested in the Designated Doctor position. NB DClarke has also since been in contact with Powys Local Health Board to discuss possible options Mr Coan to check funding stream for GP Lead for Safeguarding with Finance Department. Mr Coan to liaise with Dr Luen Wong regarding undertaking the Named Doctor for Safeguarding role for Shropshire CCG in addition to her role for Telford CCG. Child Death Overview Panel Ms Clarke advised that the Child Death Overview Panel is a statutory requirement which feeds into Safeguarding Boards. Nationally, certain CDOPs are being combined, and Shropshire CCG have been in discussion with Herefordshire CCG, Worcestershire CCG, and West Mercia Police and the Local Authorities and Public Health with a view to creating a joint CDOP. It has been agreed that Herefordshire and Worcestershire will work together to improve their current situation, and the Shropshire and Telford & Wrekin CDOP will continue as a separate CDOP, but with a view to merging within 6-12 months. A further call is planned. QC-2019-03.038 – Enhanced Care Home Framework - Update The purpose of Mrs Hassall’s report was to update the Quality Committee regarding progress on the Enhanced Health in Care Homes programme of work. Key issues or points to note were:-

Since the previous update at Quality Committee, there have been regular bi-monthly meetings with NHS England, Telford and Wrekin CCG and Shropshire CCG to progress actions and consider merging the Care Home Framework. Shropshire CCG and Telford CCG are working collaboratively to implement the programme in line with NHSE Sustainability and Transformation Plan (STP) approach.

The shared programme of work is within this report as full merger has not been agreed at this point.

Key issues to note within the framework are the roll out of the ‘Red Bag’ scheme, and that currently 15 Care Homes now have nhs.net email accounts. A focussed piece of work is being led by Shropshire Partners in Care to support the roll out of this further.

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Mrs Hassall referred to the Red Bag Scheme which Telford & Wrekin CCG had been piloting since May 2018 and which Shropshire CCG are about to roll out in April. This scheme would work in conjunction with the Care Home Advance Scheme where residents are assessed within a Care Home by a GP with a view to future planning. Care Homes who have signed up to the Care Home Advance Scheme were required to write a Care Plan for their patients. The number of Care Plans in place is monitored by the Primary Care team. ACTION: Gail Fortes-Mayer to be invited to attend the May or June Committee to present on the Enhanced Care Home Framework. QC-2019-03.039 – Healthwatch Ms Cawley sent her apologies, therefore no Healthwatch update was provided. QC-2019-03.040 – Out of Hours Procurement – Quality Impact Assessment Review and Recommendations The purpose of Ms Clarke’s report was to highlight concerns about the newly procured Out of Hours Service provider reducing the designated base from which services are provided and whether the quality impact assessment (QIA) undertaken at the start of the process would have ensured this did not happen without proper engagement with the public. The QIA process for the out of hours specification has therefore been reviewed to advise of recommendations for other procurements going forward. Recommendations were included in the paper. This included the need for specific requirements included by a CCG within the specification (in this instance the requirement for the provider to continue with existing designated bases unless discussed with the CCG) to be questioned at the procurement stage. After the tender was agreed, the new provider amended the bases and there was concern that this should have been picked up as part of the QIA assessment. If the question had been asked at the procurement stage then the issue may have been avoided. The Committee agreed that the CCG should consider how to better seek positive assurance from providers. ACTION: Gail Fortes-Mayer to be invited to attend the May or June Committee to consider how this could be included in future procurement requirements QC-2019-03.041 – Continuing Healthcare (CHC) and Complex Care The purpose of Ms Shaw’s report was to provide an update on CHC and Complex Care, identifying certain opportunities for standardisation and development of CHC processes. This report outlines planned

developments within the service over the next three months. Key points to note were:-

The introduction and set up of a weekly reporting tool in line with identified Key Performance Indicators across the service to allow for close performance monitoring.

The Funded Nursing Care cohort of 862 active cases has a significant number of overdue reviews.

There is a significant need to develop the Personal Health Budgets process within the Complex Care Team in alignment with NHS England requirements of 220 to date, and between 320 and 450 by March 2020. Shropshire CCG currently have 24 patients funded by a Personal Health Budget.

A number of substantive posts had not been recruited to and had been left vacant compounding the issues. 6 are currently out to advert, one of which has now been filled. A high number of Agency staff is being used. A duty desk nurse is being appointed to enable the band 7 MH and LD nurses to focus on Complex Care issues rather than CHC and for the band 7 CHC nurses to focus on supervising and monitoring of processes rather than acting down. An issue of concern was that ratifications were delayed, which was impacting on financial planning. This has been addressed and the time taken for ratifications has been considerably reduced. A new process has been introduced and monitoring is taking place. However, there is still a backlog of appeals. The financial forecast for the forthcoming year has been signed off. QC-2019-03.042 – 2019-20 Clostridium Difficile Infection Objectives for Shropshire CCG and Local NHS Organisations Mrs Hassall was in attendance to present Mrs Kidson’s report to the Committee in her absence.

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The purpose of the report was to inform the Quality Committee of the changes to the national Clostridium Difficile Infection (CDI) reporting algorithm and the CDI objectives for financial year 2019/20. The changes are:-

Adding a prior healthcare exposure element for community onset cases.

Reducing the number of days to apportion hospital-onset healthcare associated cases from three or more (day 4 onwards) to two or more (day 3 onwards) days following admission.

CDI Objectives for 2019/20 are based on the out turn for 1 April 2018 to 31 December 2018 using the new case definitions as highlighted in the report. The target for Shropshire CCG had been considerably reduced from 72 cases in 2018/19 to 43 cases in 2019/20, a reduction of 40%. QC-2019-03.043 – Points to Escalate to CCG Board The following items are to be discussed at the next Exec Team meeting:-

Learning Disability Health Checks

Confirmation of Executive Lead for SEND if no fixed arrangements in place by the time Ms Clarke leaves

Recruitment of GP Safeguarding Lead QC-2019-03.044 – Any Other Business West Midlands Quality Review The Committee discussed the possibility of a joint response to the review. However, the Committee agreed that each CCG should prepare an independent response to the feedback received. 0-25 Lessons Learned Dr Davies requested that an item should be placed on the Quality Committee Agenda regarding 0-25 to include input from the Lessons Learned document and the Internal Audit report. ACTION: Mr Trenchard to be invited to present to a future Quality Committee regarding 0-25. QC-2019-03.045 – Date and Time of Next Meeting The date of the next meeting is Wednesday 24 April 2019 at 2.00 p.m. in Meeting Room B, William Farr House.

UNCONFI RMED

Shropshire CCG Governing Body: 8.05.19


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System A&E Delivery (SAED) Board Meeting Tuesday 26th March 2019 – 14:30 - 16:30

Seminar Room 2, SECC, RSH

Notes Present: Dave Evans (Chair) DE AO T&W CCG

Claire Old CO Urgent Care Director Jan Ditheridge JDi Chief Executive Shropcom Pete Mason PM NHSI Tanya Miles TM Deputy Director of Adult Social Care, Shrops LA Michael Mackintosh MMc Project Manager UEC Julie Davies JD Director of Performance and Delivery Nigel Lee NL Chief Operating Officer, SaTH Terry Harte TH Healthwatch Jess Sokolov JS Medical Director SCCG

Dial in: 1. Apologies: Lucy Roberts Simon Wright Clive Jones Nicky Jacques Jess Sokolov Ange Begley Mark Brandreth Dawn Clarke Simon Freeman Russell Muirhead Clive Wright Paul Bayliss Amanda Edwards 2. Minutes and Action Log of Previous Meeting: Minutes from previous meeting approved as an accurate record. New actions from this meeting:

1. Tanya Miles to request the evaluation of SaTH2Home from Gemma McIver and Nigel Lee to bring to the next meeting

2. Dave Evans to speak to Simon Wright to discuss and find a solution to finding physical space to enable integrated discharge teams to co-locate.

3. Nigel Lee to ensure appropriate conversations take place in relation to the baseline capacity agenda item as soon as possible, before the next time the board meets.

4. Julie Davies to take to the A&E Delivery Group how we do the piece of work around workforce analysis

5. Nigel Lee to bring a report regarding the actions necessary to improve pre-12 discharges to the national average.

3. Urgent & Emergency Care Escalation Meeting Claire Old updated the room on the outputs of the escalation meeting as many in the room could not make it. She discussed the feedback letter, as per below. 4. Urgent & Emergency Care Escalation Feedback Letter Members were reminded that the letter should not be shared outside the board. Claire Old highlighted that the system needs to respond to the letter, circulating actions and working up a

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response. Pete Mason confirmed that there are no more meetings scheduled at present. The belief is that they will continue, but lack of clarity around timings and format. 5. EU exit Dave Evans confirmed that planning goes on, but not aware of any risks identified within any system organisation (daily sit-reps going in from all organisations) that will impede progress on this. This opinion was agreed throughout the room. Claire Old discussed that any issues were being channelled through the 10.30 call. 6. A&E Delivery Group Workshop 1 Julie Davies fed back the outputs from the first workshop. The A&EDG reviewed all 6 HICs, answering 4 key questions, below:

Would it be a risk to system resilience if the work was stopped?

Can the A&EDG continue to influence the progress of such work?

What would be different moving forward?

Is the HIC to be a HIC continuing into 2019? The highlighted points in discussion were:

Integrated discharge to be co-located, so a space/room needs identifying and providing at RSH – the block in this instance is estate.

Frailty front door service needs implementing at PRH and consolidating at RSH.

ED systems and processes felt to be critical in remaining a HIC for 2019 – plenty more work to do.

Demand and Capacity – crucial to system delivery but not a HIC, but a vitally important underpinning workstream to all other HICs. Needs support from A&EDB to identify a system lead to own this piece of work (Julie asked for permission to approach Simon Roberts to come and help further develop this piece of work – she will bring a business case back to A&EDB next month).

Dave Evans challenged the need for ED processes and SAFER to be a HIC for the system – suggesting that it is a SaTH internal piece of work in terms of responsibility. Julie agreed this is not a system HIC, but so important in improving system performance for A&E which relates so closely to this boards remit, so having them involved in A&EDG keeps close eye on this. Dave challenged that appropriate metrics for performance should be reported back to group, and subsequently board and at this point scrutiny be applied. Claire Old counter-challenged that we have made progress to acknowledge that the system has successfully identified that A&E performance is a system issue and by it having attention and scrutiny within the groups it has enabled the positive steps we have made. Further discussion on whether the system can actively effect this work ensued, and it was summarised that the group can monitor and help when system partners have a role to play. Dave suggested that the system elements of the ED and SAFER work could in fact fall into the demand piece. But the actual internal processes remain a SaTH piece of work, opposed to a matter for system group and board. These are going to be worked through and discussed at the second A&E Delivery Group workshop. Overall decision was to take this back to A&EDG workshop 2 on 2/4/2019 and discuss – with the idea to develop strong metrics and monitor performance and understand if on/off trajectory and facilitate discussion at this point when required.

Ambulance – New piece of work and will have more detail following deep dive.

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7. Baseline capacity at SaTH – proposal to work with ECIST Nigel discussed. Suggestion in the next couple of days to bounce the latest version off those involved to consolidate progress and understand position. The work looks at demand and core bed base, takes out Paeds beds and others. It focuses on > 0 LOS, and includes sensible assumptions around assessment units and corridors – and seeing what this means in terms of demand. Further caveats to assume we don’t use day surgery and understanding around electives. This provides core bed base and then looking at some other opportunities e.g. bay 7 at Telford and winter beds. Then looking at process-based opportunities such as AMU/AEC. Claire Old challenged based on discussions at space utilisation meeting - how we can discharge to SaTH2Home nursing home beds (buying this capacity) but can’t discharge into current vacant capacity. This needs discussing as a system. Julie Davies requested that Sath2Home data needs to appear on the dashboard. Jess Sokolov worried as a clinician that we don’t have data to represent the numbers of patients on corridors. This data needs capturing and we need to know where they are. Nigel Lee summarised from SaTH perspective – need discussions in next week with others (e.g. ECIST) to bounce ideas off one another. It is trying to use sensible assumptions, considering affordability and also workforce. Jess Sokolov asked about the live bed bridge report and if it to be shared with others. Julie confirmed that this is the dynamic bed model and hoping to have it finalised in the next few weeks once caught up with Karen Barnett. 8. Winter schemes? – continuation Nigel Lee – if going to maintain capacity into April, then winter beds need to stay. Asked for confirmation from the system to do this. Won’t get through April without this. It was to alert this group but final decision sits within SaTH. Julie asked for confirmation around future of W35. SW has asked senior leadership team to confirm how we are going to use it best. There are serious works that need to be done to compartmentalise the basement to reduce fire risk. There is serious risk that this could cause temporary closure of the entire Copthorne building if works not done immediately, so a real priority. 9. Support to SaTH from Jon Scott This discussion was around timescales – he has just 2 sessions remaining and due to end mid-April. 10. UTC tender – update Julie Davies: Great support and advice coming from regulators. How do we go to market appropriately, to be compliant with national guidance? There are 2 pieces of work to take forward:

1. Shropshire needs conversation with IMH as they provide service here and contract ends in October. Needs to be conversation on Telford side around current arrangements at PRH

2. Need 3 way exec to exec conversations between SaTH and CCGs, how it would work, what would be role of SaTH, are they lead provider, how does it link with future fit etc. to work this through – the outcome would be a paper to take to relevant governing bodies. Wouldn’t want to do this work over the winter so a best start date would be 1st April 2020. Pete Mason from a regulator perspective said a delayed timeline of implementation may have to be sanctioned – in terms of patient safety.

11. Workforce – what are our system gaps? Jess Sokolov stated that we don’t have enough clarity around workforce to deliver on plans. Need to understand gap and how we bridge it, or how we don’t bridge it but plan to mitigate.

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There are no hard workforce analyses to help illustrate this. There were concerns around recent suggestions of increasing capacity when only 4 acute physicians. Dave Evans explained that Dale Bywater does not expect to see another bid from this system for additional beds until evidence of robust plans around workforce. Jan Ditheridge said that we need to start looking more at workforce to understand gaps and then allow for planning re recruitment, or at least what would we do differently if we cannot staff properly. Jess added that we need to know what we have in terms of workforce for next time we go to an escalation meeting. Dave Evans says that we should be able to map out demand and capacity, and then establish what the capacity gap is and where are the workforce to meet this demand. This should be an effective piece of work to help understand this issue more. Julie Davies developed this, stating that we need to do this modelling work in 2 scenarios, planning for the worst and also planning ambitiously – as the system is in transition. Jess agrees this is the right thing to do, when this comes back she wants clear understanding on how the gap influences the options on how to manage it. Action: Julie to take back to delivery group to see how we do this piece of work. 12. A&E trajectory Nigel – there isn’t a current trajectory. Pete Mason said that 80% was original target but there had been mention of improvement expected upon the 80% and a move towards 90%. This may be unrealistic. Nigel wants to get to 80% and sustain before looking onwards and upwards and this was agreed in the room. In terms of 90%, Nigel would need to discuss with Simon about how this is built up. Immediate threats to achieving over 80% are workforce and other things that restrict these solutions, such as finance. A session on trajectories follows this meeting so will be able to feed back more detail next time. 13. Update on the future of A&E Delivery Board & Group- not discussed at Senior Leaders Forum so deferred. 14. A&E monthly dashboard report Claire Old summarised report provided by Charles:

demand higher for ambulance and walk ins.

Stranded and super stranded, stranded are becoming higher share of stranded patients – which is not what we want. This change is significant. This effect is inflated at RSH due to having 3 wards closed. Julie Davies wants us to sense check this for IPC. Dave Evans wants us to know what is happening particularly at RSH, as it seems to be on the rise, whereas PRH looks to be relatively consistent. There were questions around the fragility and sustainability of this – it needs to be maintained and not crisis managed. Claire identified that the workshop says this work needs to be business as usual rather than infrequent and changing initiatives.

Management of pressures – dashboard helping this as it highlights these issues

Action: Dave Evans wants to know what the action plan is to improve pre-12 discharges, as well as MFFD for POWYS. Nigel Lee to bring a report regarding the actions necessary to improve pre-12 discharges. 15. AOB Tanya Miles: last meting discussed an action to bring back evaluation of SaTH2Home – so Tanya to ask Gemma McIver and Nigel Lee to bring it to the next meeting. Meeting Closed


Shropshire CCG Governing Body meeting: 8 May 2019


Name of Committee:

North Locality Board Meeting

Date of Meeting:

28th February 2019

Chair:

Dr Michael Matthee


Right Care data pack

- New way of working for the Board

- A decision was made to look at respiratory first

Care Closer to Home

– This is supported by Members

Maternity Update

- Issues were raised again re the prescribing of pethidine

- No real changes or improvement from before as regards to the notification of

pregnancy/medication

Chairs are working on making sure the meeting is more commissioning-based, allowing

Members to influence and contribute to commissioning, rather than people attending the meeting

to provide updates on what has already been decided


No actions required

North Locality Board Meeting – 28 February 2019 Page 1

Shropshire CCG Governing Body – 08.05.19 Agenda Item: GB-2019-05.083a


William Farr House Mytton Oak Road

Shrewsbury Shropshire SY3 8XL

Name Practice/Organisation Signature

Dr Adam Booth Baschurch Attended

Nicolas Storey Baschurch Attended

Dr Tim Lyttle Churchmere Medical Group Attended

Jenny Davies Churchmere Medical Group Apologies

Dr Geoffrey Davies Clive Apologies

Dr Angela Ayers Clive Attended

Zoe Bishop Clive Apologies

Dr Naresh Raichura Hodnet Attended

Christine Charlesworth Hodnet Apologies

Dr Jonathan Davis Knockin Apologies

Mary Herbert Knockin Attended

Dr Mike Matthee (Joint Chair) Market Drayton Attended

Michele Matthee Market Drayton Attended

Dr Santiago Eslava Oswestry Cambrian Medical Centre Attended

Kevin Morris Oswestry Cambrian Medical Centre Attended

Dr Stefan Lachowicz Oswestry Caxton Attended

James Bradbury Oswestry Caxton Attended

Dr Yvonne Vibhishanan Oswestry Plas Ffynnon Attended

Sarah Williams Oswestry Plas Ffynnon Attended

Dr Alistair C W Clark Shawbury Attended

Jane Coles Shawbury Apologies

Dr Catherine Rogers Wem / Prees Attended

Richard Birkenhead Wem / Prees Attended

Dr Katy Lewis (Joint Chair) Westbury Attended

Helen Bowkett Westbury Apologies

Dr Ruth Clayton Whitchurch – Dodington Attended

Elaine Ashley Whitchurch – Dodington Attended

Elaine Gough Ellesmere Patient Participation Group (PPG) Representative Apologies

Dr Julian Povey CCG Chair Attended

Dr Simon Freeman CCG Accountable Officer Attended

Dr Jessica Sokolov CCG Medical Director Apologies

Nicky Wilde CCG Director of Primary Care Attended

Janet Gittins CCG North Locality Manager Apologies

Heather Clark (Minutes) CCG Personal Assistant Attended

Tom Brettell CCG South Locality Manager Attended

Amanda Laing CCG North Locality Pharmacist [Item 8] Attended

Clare Michell-Harding CCG Senior Project Lead Pharmacist [Item 8] Attended

Gail Fortes-Mayer CCG Director of Contracting and Planning [Item 5] Attended

Fiona Ellis CCG Programme Lead for Local Maternity System [Item 6] Attended

Louise Watkins SaTH Matron MLUs and Community Services [Item 6] Attended

Anthea Gregory-Page SaTH Deputy Head of Midwifery [Item 6] Attended

Lisa Wicks CCG Deputy Director of Performance and Delivery [Item 7] Attended

Dr Finola Lynch CCG Vice-Chair [Item 7] Attended

Dr Clare Hurst South Locality GP [Item 7] Attended

Dr Catherine Beanland South Locality GP [Item 7] Attended

Dr Kieran McCormack Shrewsbury & Atcham Locality GP [Item 7] Attended

Minutes of the

North Locality Board Meeting

Thursday 28 February 2019

Drayton Medical Practice


Minute No NLB-2019-02.019 [Item 1] - Welcome & Apologies

1.1 Dr Michael Matthee welcomed and thanked those present for attending. Apologies were recorded as above.

Minute No NLB-2019-02.020 [Item 2] - Members’ Declarations of Interests

2.1 There were no further interests declared for items included on this meeting’s agenda.

ACTION: For those Members who had not already submitted a new Declaration of Interests

form they were requested to complete and sign and forward or hand to Heather Clark.

([email protected])

Minute No NLB-2019-02.021 [Item 3] - Minutes of Meeting held on 24 January 2019 3.1 The minutes of the previous meeting held on 24 January 2019 were accepted as a true and accurate

record and were signed by the Chairs. Dr Booth expressed his thanks for the minutes coming out earlier than they used to.

3.2 All outstanding actions from the last meeting had been completed apart from the following which will

be carried forward to the next meeting.

ACTIONS: Minute No NLB-2018-10.092 - Dr Lewis to chase consultant and update at next

meeting re discussion on heart failure and AF.

Janet Gittins to ask Dr Julie Davies to provide an update on physiotherapy referrals for the

next locality meeting.

Minute No NLB-2019-02.022 [Item 4] - Matters Arising not covered on the Agenda 4.1 No further matters were raised. Minute No NLB-2019-02.023 [Item 5] – Right Care Data Pack

5.1 Gail Fortes-Mayer and Dr Simon Freeman talked through a presentation about NHS Right Care to explain to locality members what drives commissioning and the data behind it. They covered the following areas:

What is NHS Right Care

The Right Care methodology

Variation by programme

CCG headline variation in: Detection, NEL admissions, Bed days, long stay patients, elective admissions, primary care prescribing

Midlands and East system wide opportunity analysis

Where to look: respiratory, CVD and MSK

Next steps for the North Locality The charts and data were discussed and explained to Members and longer discussions took place around the three identified areas where potential savings could be made (respiratory, CVD and MSK), and concerns were raised around funding and capacity in the systems.

5.2 It was decided by Members that they would like to concentrate on respiratory first and Dr Freeman

advised that Gail Fortes-Mayer would support the locality in putting a proposition together for the CCG. This will cover what work and funding would be needed to look into respiratory further e.g. looking at other CCGs to see what they have done, looking at PCN’s and how they could work together, and looking at practice data and records. It was also suggested that it might be a good idea to review some hospital records which would require some Members to sign an honorary contract with the hospital in order to review the notes. Once this has been done it was suggested that a consultant from SaTH could be invited to the Locality Board meeting and maybe someone from another CCG that were performing well in respiratory.

ACTION: Gail Fortes-Mayer to support locality in putting a proposition/proposal together for

the CCG to detail the work and funding needed in order to look into respiratory further.



Minute No NLB-2019-02.024 [Item 6] – Maternity Update

6.1 Fiona Ellis, Anthea Gregory-Page and Louise Watkins attended the meeting to give an update on maternity services. Anthea asked for members to advise her if they are not receiving pregnancy notifications. Some practices confirmed that they do not get weekly lists but do still get notifications for individual patients. It was stated that all practices should be receiving weekly lists even if there are no pregnancies. Confirmation has been given to Andrea by the administrative team manager that these notifications are being sent. Dr Povey asked the team to complete an audit of last month’s notifications to find out where they are being sent to.

ACTIONS: Members to advise Anthea Gregory-Page/Louise Watkins if they are not receiving

electronic notification of pregnancies.

Fiona Ellis to complete an audit of last month’s pregnancy notifications to find out if they are

being sent and if they are being sent to the correct email addresses.

6.2 The midwifery team are progressing to using smart cards so that everything that needs to go onto summary care records will be put on there by midwives. The midwives will only have access to see and update certain parts of records.

6.3 Anthea Gregory-Page also talked about the issue that was raised at a previous meeting about the

prescribing of pethidine. She explained that it had been confirmed by SaTH that midwives delivering home birth care do not provide pethidine, as legally the midwives are not allowed to carry it. A leaflet that is given out to patients states that patients should speak to their GP about prescribing this, but this can be removed if needed. There was an agreement from Members that they do not want to prescribe something where they are not involved at all, and this prescription should come from SaTH. All agreed that they will not prescribe pethidine. Clare Michell-Harding advised that she was also looking into this from a medicines management perspective and was in discussions with SaTH about this. Dr Povey stated that this is a service that is provided in the community by SaTH and therefore should be prescribed by the trust. Louise Watkins also mentioned the problems the team were having with prescribing the higher dose of folic acid for patients with increased BMI. Dr Povey advised this was the same as the issue with pethidine; the responsibility should lie with SaTH.

ACTIONS: Anthea Gregory-Page/Louise Watkins to remove sentence from home birth leaflet

about patients talking to their GP for prescribing of pethidine.

Dr Povey/Chairs to discuss pethidine and folic acid prescribing issues with Jessica Sokolov,

Medical Director.

6.4 Fiona Ellis talked about ongoing campaigns that the Local Maternity System was working on such as raising awareness of reduced foetal movements, the baby buddy app, and the movements matter video. She explained that there were also banners available to promote the campaigns which were being circulated around practices. Fiona mentioned a programme that was running for motivational interviewing which is primarily for midwives but is being opened up to GPs too; this will give training about the way in which consultations and conversations happen to help with patient choice and decisions. There was general agreement that this was not needed for GPs as they do not have involvement anymore in pregnancies.

6.5 The MLU (Midwife-Led Unit) review is in the process of getting the options appraisal complete in order

to secure NHS England assurance. There have been two recent stakeholder events of which the last was yesterday. The options preferred are: retain the consultant unit, free-standing midwife-led unit and alongside midwife-led unit, supported by a number of hubs around the county. The proposal for the hub locations are two in Telford and one in North Shropshire and one in South Shropshire, but not Oswestry and Bridgnorth. This decision was made by looking at populations, activity and deprivation in eight areas of Shropshire (3 in Telford, 1 in Shrewsbury, 1 in North, 1 in South, 1 in Bridgnorth and 1 in Oswestry). It is not sustainable to have a hub in each eight areas. The hub in the North will possibly be in Whitchurch or Market Drayton but is still to be decided. The two MLU’s will be open 24/7 but patients will also get all their routine ante-natal and post-natal care close to where they live; the hubs will offer different services such as perinatal mental health services, obstetric clinics, outreach clinics, and will be tailored to the need in each area.


Minute No NLB-2019-02.025 [Item 7] – Shropshire Care Closer to Home (SCCtH) 7.1 Dr Finola Lynch and Dr Yvonne Vibhishanan talked through the care closer to home presentation

which covered the following areas:

The problems the CCG is trying to solve

Information about phase 1 Frailty Intervention Team

Information about phase 2 risk stratification, case management and pilot sites

Information about the services in phase 3: Rapid Response, DAART, Crisis Intervention, Hospital at Home, Step-up beds

Role of the GPs on the working group

Benefits to GPs and Patients

Challenges by GPs

Next steps 7.2 Dr Lynch stated that the team needed a few more practices to be control sites for phase 2 and asked if

any other practices were interested, the team would only need access to data at the practice to compare whether the service is having the impact it hoped for.

ACTION: Members to contact Finola Lynch if they are interested in being a control site for care

closer to home phase 2. ([email protected])

7.3 Dr Tim Lyttle asked what that timescale and process was for assessing affordability. Dr Lynch explained that there was already a community service contract with 91 services, but this was a block contract and therefore the money being spent is at a high tariff for a service that is not delivering. Also if this service starts to help avoid inappropriate admissions the money saved will be fed back into these services being designed. Lisa Wicks explained that she was at a system leadership meeting where Sir Neil McKay, the STP Chair, stated that this programme of work was so significant that he has asked for a business case so they could invest pump-prime funding.

7.4 Dr Beanland voiced concerns about the project, but stated that if it could be achieved it would be

great. She advised that she was not convinced that this would reduce work for GPs and thought it might increase the number of home visits. Dr Beanland also raised concerns about access for patients in rural areas.

7.5 Dr McCormack agreed with Dr Beanland’s point about GPs having a lot of work to do and that they

have already taken on work from other services that can’t cope. These services are not supposed to be in general practice and SCCtH should be a virtual ward that is not part of GMS and will be secondary care responsibility. Dr Lewis added that the main concern is that a lot of these services rely on joined up working with the Local Authority to provide care; in some areas it is already hard to get carers and some won’t come out to rural areas. Dr Vibhishanan suggested that it may be a good idea for Dr Beanland’s practice to be one of the control sites.

7.6 A discussion took place about concerns around funding; workforce issues, capacity and PCNs. Nicky

Wilde advised not much is known about PCNs at the moment other than there would be five specifications as part of the DES. She explained that it is hoped that by the time the pilot is complete that there will be more information about the requirements for networks. There are also a number of work-streams that are looking into workforce requirements and training. Dr Lynch advised that the Local Authority and Community Trust are both involved in discussions and have both signed a memorandum of understanding for the project.

7.7 A question was asked about community beds. Dr Lynch advised that these were part of the

community offer but work on this was not able to start at the same time as the other services; a needs impact assessment was needed to be completed by the Council which caused a delay. This area will require some expertise and the CCG may need to bring in an external agency as it is important to get this right.

Minute No NLB-2019-02.026 [Item 8] – Prescribing Update

8.1 The prescribing update paper was circulated to Members prior to the meeting; it was agreed that at the next meeting the prescribing update would be in the beginning half of the meeting.

8.2 It was confirmed that coils should not be prescribed and the Medicines Management Team were

aware that GPs were being asked to prescribe them. There is a block contract in place for this.



8.3 It was confirmed that Michele Rowland-Jones was aware about issues with Hepatitis B immunisations.

This is sponsored by NHS England but is not in the contract, there has been a letter from NHSE stating that GPs should be providing these immunisations, though guidance from the LMC states they should not. The team have been told that SaTH can’t do this as they do not have enough staff, and patients are going straight into dialysis and are not being seen in outpatients first; some people have been affected by this.

8.4 Clare Michell-Harding advised that the CCG had agreed a policy for Tresiba, this is for type 1 diabetes

patients and a small cohort of type 2 patients – type 2 only on consultant recommendation following an MDT in hospital; they have to maintain prescribing until the patient is stabilised and then can be passed to primary care. The policy will be on the CCG website soon.

Minute No NLB-2019-02.027 [Item 9] – PPG Update 9.1 Apologies were received from Mrs Elaine Gough and therefore there was no PPG update. Minute No NLB-2019-02.028 [Item 10] – CCG and Locality Update 10.1 Dr Julian Povey explained that the CCG had found a replacement for Simon Freeman and were

recruiting David Stout as the new Accountable Officer. David is an experienced NHS senior leader and has been involved in Richmond CCG and bringing together the North London STP. David will be invited to locality meetings to meet everyone after he starts.

10.2 The Shropshire, Telford and Wrekin STP have a new leader, Sir Neil McKay, who could also be invited

to locality meetings to meet members if wished. This year the STP has to submit a combined plan showing the control total for the system. The system should have a £3m surplus if all the control totals are combined, before QIPP and saving plans the gap is currently £55m on a system total of about £800m. The CCG is likely to meet the control total of £12.3m and will need to have a QIPP next year of £30m; there will be a lot of financial challenges.

10.3 The CCG has to reduce running costs by 20% by April 2020; the CCG is already 10-20% over running

costs. The most likely way to cut costs will be to look at how to work more closely with Telford and Wrekin CCG. In the NHS long term plan it talks about having one commissioner per STP, therefore there may be one joint management team in a years’ time and it may be an opportunity to look at one CCG to cover both areas. This will be discussed at the CCG Board and will be worked up with Members involvement. There are implications for staff and the way both the CCGs work, but there will be a formal legal HR process; there are no definite plans as yet.

10.4 Dr Povey thanked Dr Matthee and Dr Lewis for doing such a good job since they started their Locality

Chair positions. Minute No NLB-2019-02.029 [Item 11] – Primary Care Update 11.1 The Primary Care update paper was circulated to Members prior to the meeting; there were no further

questions raised about this. Minute No NLB-2019-02.030 [Item 12] – Commissioning Update 12.1 The Commissioning update paper was circulated to Members prior to the meeting; there were no

further questions raised about this. Minute No NLB-2019-02.031 [Item 13] – Locality Assurance Framework 13.1 The Locality Assurance Framework was circulated to Members prior to the meeting; Members queried

whether the item about violent patients needed to remain on the framework. Nicky Wilde advised that the CCG was ready to commission the zero tolerance enhanced service with a practice in Telford, but the CQC score for the practice was not very good. It was therefore recommended by NHS England that the service should not be held at this practice; it will now be part of the Whitehall practice contract. Members agreed that this issue could now be removed from the Locality Assurance Framework.

Minute No NLB-2019-02.032 [Item 14] – Any Other Business 14.1 Dr Katy Lewis explained that a suggestion had been made that Locality Board’s function in a similar

way to the CCC working group; with papers being submitted for clinical input and feedback. Items would come from the CCC working group to the Locality Boards before they are then sent to CCC to


be ratified. This would give a chance for members to change what is in contracts and specifications and influence commissioning more. Dr Booth stated that the Locality Board today was a step in the right direction and that it was useful to go over data and see the reasons behind CCG proposals. Dr Lewis also stated that peer review could be undertaken at the meetings.

14.2 Discussion took place about the format and location of the locality meetings and a decision was made

that a provider session should take place from 1.30-2.30pm with the commissioning section following from 2.30-5.30pm. Suggestions for more central locations were made and it was agreed to contact Ellesmere Town Hall and other locations to see if they were available for the meeting dates already booked in the future. It was agreed that the next meeting’s discussions should cover respiratory and anything that comes from the CCC working group.

ACTION: Heather Clark to make changes to future meeting agendas and contact more central

locations for availability.

14.3 A question was asked about referrals into Wrexham and that the RAS team said they could not do anything about these referrals. This was confirmed, anything referred into Wales doesn’t go through the RAS team.

Minute No NLB-2019-02.033 [Item 15] - Date of Next Meeting 15.1 The next meeting will take place on: Thursday 28 March 2019 at The Venue at Park Hall, Burma

Road, Park Hall, Oswestry, SY11 4AS commencing at 2.30pm. A provider session will take place before the locality board from 1.30 – 2.30pm.

Future Meeting Dates

Tuesday 30 April 2019 – PLT

Thursday 23 May 2019, Drayton Medical Practice, Market Drayton

Thursday 18 July 2019, The Venue at Park Hall, Oswestry

Thursday 26 September 2019, Drayton Medical Practice, Market Drayton

Thursday 28 November 2019, The Venue at Park Hall, Oswestry

Further PLT dates to be confirmed.

Signed: …………………………………............ Date: ….........................…………. Dr Michael Matthee, Joint North Locality Chair Signed: …………………………………............ Date: ….........................…………. Dr Katy Lewis, Joint North Locality Chair

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Name of Committee:

Shrewsbury and Atcham Locality commissioning Committee

Date of Meeting:

Thursday 21st February 2019

Chair:

Dr Deborah Shepherd


Information regarding the new Accountable Officer and Governing body members

Prescribing update – information regarding the development of the new net formulary

Presentation and discussion around Looked After Children and SEND children – methods of

Local Authority and GPs sharing information about these children for statutory assessments and

other concerns

Presentation on the MacMillan Community and Care Coordinators project – a successful bid for

funds to expand the C&CC role to support patients living with and beyond cancer

Clinical discussion on paediatric asthma care.


Shrewsbury & Atcham Locality Board Minutes – 21 February 2019 Page 1 of 5

Shropshire CCG Governing Body – 08.05.19 Agenda Item: GB-2019-05.084a

Shropshire Clinical Commissioning Group William Farr House

Mytton Oak Road Shrewsbury Shropshire

SY3 8XL


Dr D Shepherd (Chair) CCG Locality Chair & Locum GP Attended

Dr J Pepper Belvidere Attended

Caroline Davis Belvidere Attended

Dr M Fallon Claremont Bank Attended

Jane Read Claremont Bank Attended

Dr E Baines Marden Attended

Zoe George Marden Attended

Dr Julia Visick Marysville Attended

Izzy Culliss Marysville Attended

Dr Sarah Watton Mytton Oak Apologies

Adrian Kirsop Mytton Oak Attended

Dr R Bland Pontesbury Apologies

Heather Brown Pontesbury Attended

Dr H Callahan Radbrook Green Attended

Angela Treherne Radbrook Green Apologies

Dr P Rwezaura Riverside Attended

Tracy Willocks (Vice Chair) Riverside Attended

Dr D Martin Severn Fields Apologies

Tim Bellett Severn Fields Attended

Dr L Davis South Hermitage Attended

Caroline Brown South Hermitage Attended

Dr E Jutsum The Beeches Attended

Kim Richards The Beeches Apologies

Jo Beason Whitehall Attended

Dr K McCormack Worthen Apologies

Cheryl Brierley Worthen Apologies

Roland Brown Severn Fields PPG Apologies

Jenny Birch Belvidere PPG Attended

Tina Sandford Severn Fields PPG Attended

Dr Julian Povey CCG Chair Apologies

Dr Simon Freeman CCG Accountable Officer Apologies

Nicky Wilde CCG Director of Primary Care Apologies

Jenny Stevenson CCG Locality Manager Attended

Heather Clark (Minute Taker) CCG Personal Assistant Attended

Steve Ellis CCG Head of Primary Care [Item 6] Attended

Michele Rowland-Jones CCG Interface Care and Commissioning Pharmacist [Item 6] Attended


Indi Kaur CCG Locality Pharmacist [Item 6] Attended

Maggie Braun CCG Designated Nurse for Looked After Children [Item 8] Attended

Carol Richardson CCG Interim Designated Clinical Officer for SEND [Item 8] Attended

Dr Gill Clements Macmillan GP Facilitator [Item 9] Attended

Dr Martyn Rees Consultant Paediatrician (General & Respiratory), SaTH [Item 12] Attended

Lynnette Charles Respiratory and Allergy Nurse Specialist, SaTH [Item 12] Attended

Lynn Nicholls CCG Commissioning and Redesign Support Officer [Item 12] Attended

Bethan Emberton CCG Commissioning and Redesign Lead – Planned Care & Long Term Conditions [Item 12]

Apologies

Minutes of the Shrewsbury & Atcham

Locality Board Meeting

held at 2.00pm on Thursday 21 February 2019

in Board Meeting Room, 2nd Floor, Severn Fields Health Village,

Sundorne Road, Shrewsbury, SY1 4RQ


Minute No S&ALB-2019-02.018: Item 1 - Welcome & Apologies

1.1 Dr Deborah Shepherd, Locality Chair, welcomed and thanked Members for attending and introductions were made. Apologies were noted as above. Dr Shepherd advised that it was Indi Kaur’s last meeting and thanked her and wished her good luck for the future.

Minute No S&ALB-2019-02.019: Item 2 – Members’ Declarations of Interests

2.1 Members were reminded of the governance requirement to submit annually a new completed and signed declaration of interest form, copies of which were tabled. There were no further interests declared for items included on the agenda.

ACTION: Members were reminded to submit a new completed and signed declaration of interest form and return to Miss Heather Clark. ([email protected])

Minute No S&ALB-2019-02.020: Item 3 – Minutes of Meeting Held on 17 January 2019 and Actions 3.1 The minutes of the previous meeting, held on 17 January 2019, were accepted as a true and accurate

record and were signed by the Chair, Dr Shepherd. 3.2 Jenny Stevenson talked through the outstanding actions and confirmed that all had been completed

apart from the following: BeeU Service actions in regards to an operating protocol, Maternity team action in regards to midwives prescribing anti-biotics and iron.

ACTIONS: Steve Trenchard and BeeU Service to work on operating protocol to include risk criteria for access and timescales for consultation and feedback that can be shared with GPs. Anthea Gregory-Page/Louise Watkins to send a list of the antibiotics that midwives can prescribe / information about dispensing of Iron – this is being checked and confirmed by commissioners.

3.3 Members raised an issue about the BEAM service, they have received complaints about the drop in

services; young people have been turned away as there are too many people there. 3.4 Tracy Willocks advised that the Community Matron her practice refers to is now on long term sick leave

again and nobody knows who is covering her work; this is being managed at a low level by District Nurses, but it is not clear if anybody from high level is looking into this issue. This issue needs to be escalated.

ACTION: Community Matron on long term sick leave - issue to be escalated by the CCG.

Minute No S&ALB-2019-02.021: Item 4 – Matters Arising

4.1 No items were raised for this agenda item.

Minute No S&ALB-2019-02.022: Item 5 – Locality Chair Update 5.1 Dr Shepherd explained that interviews for the new CCG Accountable Officer had taken place, a suitable

candidate was identified and the details have been sent to NHS England for approval and sign off before this can be announced.

5.2 Members should have received a letter from Dr Julian Povey in regards to new Governing Body

members who are: Dr Priya George (Governing Body GP), Dr Katy Lewis and Dr Michael Matthee (Joint North Locality Chairs), Dr Matthew Bird (South Locality Chair) and Dr Alan Leaman (Secondary Care Consultant).

5.3 There will be a more detailed update about Shropshire Care Closer to Home next month as the team are

coming to talk about the models for phase three. The pilot sites for phase two have been chosen, the eight sites are: Albrighton, Bridgnorth, Belvidere, Bishops Castle, Plas Ffynnon, Wem and Prees, Meadows in Clun and Pontesbury.

5.4 A meeting took place yesterday to look at the format of the Locality Board Meetings. Feedback received

about the meetings show that even though they are supposed to be commissioning meetings they get mixed up with provider issues, therefore other localities are going to start having separate provider meetings before or after their Locality Board meeting. Dr Shepherd asked members to think about what they would like from the meetings and to feedback to her as soon as possible. Another idea suggested



was that Dr Katy Lewis who attends the CCC (Clinical Commissioning Committee) working group could advise localities of anything that would benefit from clinical input before they are developed and referred on to CCC. It was also suggested that more peer review and data review could be brought to meetings, as well as bringing feedback on commissioning projects and coming up with suggestions for QIPP projects. It was questioned whether Practice Managers needed to be at the meetings if they were to change to a more clinical focus; Dr Shepherd advised that the terms of reference could be looked at if wanted. Dr Shepherd suggested that perhaps the meeting could take a format of having three sections: a provider session, a session for everyone and a clinical session. Steve Ellis advised that the current Provider Forum would continue even if the locality meetings are changed.

ACTION: Members to send ideas and suggestions about the format of the Locality Boards to Dr Shepherd. ([email protected])

5.5 Jenny Stevenson advised that practice data packs are being prepared and will be sent out soon, the BI

(Business Intelligence) team have been developing these to include data on A&E, outpatient and inpatients. If these packs are useful to everyone the BI team will send these out quarterly and they will be used in future practice visits.

Minute No S&ALB-2019-02.023: Item 6 – Prescribing Update 6.1 Michele Rowland-Jones advised that the team had been working on a net formulary for the whole health

economy in Shropshire. The formulary is on the internet and can also be accessed via an app on mobile phones; it is not part of EMIS, though how to link the two is being considered. The formulary provides a simple way to access information about what should and shouldn’t be prescribed, and will also highlight cheaper medications. There is an A-Z list of drugs which follows the BNF and shows the preferred choice for medicines, there is also a search option, a news feed and useful links section. There is a traffic light system for medications with green meaning can prescribe, amber meaning can prescribe but there will be some other specification (e.g. ESCA), red meaning hospital only and black meaning no longer to be prescribed. Drugs on the NHSE self-care list are also highlighted. Consultants should be using the same formulary; therefore if requests are made for a drug that cannot be prescribed the GP should speak to the consultant, referring to the formulary guidance in the first instance. There will be a formal launch to ensure everyone is aware of it and it is also in the Medicines Commissioning Framework for Hospitals.

6.2 A question was asked about the formulary and whether it could be organised nationally by NHS England

to ensure everyone prescribes the same medication. Clare Michell-Harding advised that hospitals have different drug contracts so a blanket formulary across all the country would be difficult. Each CCG currently has their own formulary; Shropshire, Telford and Wrekin CCGs have a joint one, and the CCG is also working with Telford and Wrekin CCG on standardising shared care agreements. It was confirmed that if a patient is referred to an out of county trust, that Trust has to abide by their own CCG policies rather than ours. Once the formulary is launched, any problems should be reported to the Locality Pharmacists. If OPD requests are received these can be sent to Michele Rowland-Jones so she has evidence that can be raised at Clinical Quality meetings.

Link to Net Formulary: http://www.shropshireandtelfordformulary.nhs.uk/default.asp 6.3 Indi Kaur talked through the prescribing update and confirmed that the updates will now concentrate on

locality and CCG based data. Practice Managers and GP leads will receive individual practice prescribing data. Ms Kaur advised that a new pharmacist had been appointed to replace her but has to work three months’ notice; in the meantime the locality will receive support from Clare Michell-Harding and the other locality pharmacists.

ACTION: Clare Michell-Harding to circulate email addresses to the locality members so they know who they need to contact once Indi has left.

6.4 The Shrewsbury and Atcham locality are doing well and there has been a reduction in costs of 6.92%

and a reduction in items of 0.33%. All practices are meeting the scriptswitch acceptance rate for acute, and the majority are meeting the repeat rate. Practices should have received data about antimicrobial stewardship targets, all of which have been met at CCG level and the majority at practice level. The locality has met the 25% reduction target for restricted medicines and will hopefully meet the 50% reduction target by April. Heads of Medicines Management teams in the local area will be meeting to look at ongoing issues such as restricted medicines, and information from these meetings can be brought back to the locality meetings. The CCG as a whole is not doing well on OTC medicines but the Shrewsbury and Atcham locality are doing better than others.

6.5 A question was asked about the screens in GP surgeries and whether OTC guidance could go on these.

Steve Ellis confirmed he was working on this with the communications team at the CCG. A discussion


http://www.shropshireandtelfordformulary.nhs.uk/default.asp


also took place about whether multivitamins should be requested on prescription for babies; Dr Baines stated that all children should be on multivitamins anyway in accordance with government guidance.

ACTION: Indi Kaur to look into query about prescribing of multivitamins for children.

Minute No S&ALB-2019-02.024: Item 7 – Open Discussion – “Hot Topics” from Practices

7.1 No items were raised for this agenda item. Minute No S&ALB-2019-02.025: Item 8 – Looked After Children and SEND Discussion

8.1 Maggie Braun, Designated Nurse for Looked After Children (LAC) attended the meeting to talk about the

template that is to be completed by GPs/practices for Looked After Children’s Health Assessments. The template is on EMIS and is to be done once for initial health assessments, and again for reviews which take place twice a year for 0-5 year olds, and once a year for 5-18 year olds. The request will be sent by email and the requested response time is five working days; the team are not asking the GP to see the patient, it is an information gathering exercise from patient records only. This information is requested to make the initial and review health assessments as robust as possible. GPs should receive a full assessment back from the team following the assessment. More information was provided in the resource pack that was circulated with the meeting papers.

8.2 The template was designed after a CQC inspection approximately 12 months ago, there has been a pilot

study and some promotion has been sent out about this. Shropshire CCG communications team have also been asked to send out some further information. A discussion took place about some information such as family history that will not be picked up from EMIS, Ms Braun advised that this information is whatever the practice feel would be relevant to the assessment; she advised that if things come up between assessments GPs can still contact the team using the same email address.

8.3 Members asked if the LAC team could inform GPs when children are no longer registered as LAC so that

it could be updated on their patient systems. Ms Braun advised she was aware of this and this issue has been raised before and is being looked into. She added that GPs should also be copied into review conferences and receiving minutes from them. There is a summary page that could be filed in patient records; discussion took place about this as it was felt there was too much third party information in these documents to keep in records. Some members stated that they took the basic information from the summary and typed it into EMIS so that third party information was not included.

8.4 Carol Richardson, Interim Designated Clinical Officer for SEND (Special Educational Needs and

Disability), explained that since the Act of 2014, SEND are required to provide children with Education and Healthcare Plans (EHCP). Ms Richardson explained that she was trying to roll out a process for health providers to contribute relevant information to aid the development of individual EHCPs and that GPs should already be involved in this by filling in medical questionnaires sent out by the Local Authority. Some members confirmed they had received the questionnaires but most had not. Ms Richardson advised she would check this. Members asked if the template could be an EMIS template so that someone could just press a button to fill it in. Ms Richardson offered to come to a PLT session to discuss SEND, Dr Baines advised that it may be more appropriate for a small group of GPs with a special interest to meet with her first before it is taken any further. Dr Shepherd asked for this to be investigated first and for some work to be completed with the BI team for an electronic form.

ACTION: Carol Richardson to look into whether the Local Authority are sending and receiving EHCP medical questionnaires to and from practices and to work with BI team on an electronic form for the questionnaires.

Minute No S&ALB-2019-02.026: Item 9 – Macmillan C&CC (Community and Care Coordinator) Project 9.1 Dr Gill Clements attended the meeting to talk about the Macmillan C&CC Project. She explained that she

thought the C&CC role could be expanded to support patients living with and beyond cancer, so put a bid in to Macmillan for some funding. Feedback from these patients showed they do not feel supported and have a lot of non-clinical needs. The Shrewsbury and Telford Hospital Trust also have Macmillan money for this; they are looking at how they could change the way CNSs (Clinical Nurse Specialists) work and also looking at MDTs, discharge summaries and follow ups.

9.2 The money received from the successful bid will be used to expand the current C&CC workforce; they

have been evaluated and they are excellent value for money and practices and patients like them. The project is for three years and the funding is for 4 hours per newly diagnosed patient per year, there is also money available to fund clinical leadership. Dr Clements explained that there was an opportunity to bring together this funding and the funding for the social prescribing link workers. Future work with


Primary Care Networks will also give great opportunities for full time posts and there may be an opportunity to get the University involved in a diploma course.

9.3 This project has been successfully rolled out in Glasgow with 70% of patients taking up the offer. Current

C&CCs are aware of the project and some have expressed an interest in having extra hours. The C&CCs may not have to visit all patients face to face as they could use technology such as skype or phone calls. Contracts for C&CCs in the future may go to the Networks and redundancy costs will be part of the project funding.

ACTION: Members to contact Dr Gill Clements if they have any ideas or questions about the Macmillan C&CC project. ([email protected])

Minute No S&ALB-2019-02.027: Item 10 – PPG Update and Feedback 10.1 Jenny Birch confirmed that Dr Simon Freeman attended a meeting to talk about the development of

PCNs (Primary Care Networks), and Dr Loveday from Oswestry attended a meeting to talk about Summary Care Records.

Minute No S&ALB-2019-02.028: Item 11 – Any Other Business 11.1 Clare Michell-Harding advised that a diabetes policy had recently been approved at the Prescribing

Committee meeting; this was for Tresiba which has been confirmed is mainly for type 1 diabetic patients, with a small cohort of type 2 patients. The decision about this will be made by a consultant-led MDT in hospitals, all prescribing will remain with the Diabetes Specialist Team until patients are stabilised and then referred to their GP. Also added into the policy is that Tresiba shouldn’t be used first line and they need to have tried other therapies first; the policy will be on the CCG website soon.

Minute No S&ALB-2019-02.029: Item 12 – Discussion on Paediatric Asthma Care

12.1 Members split into two groups to discuss Paediatric Asthma Care and Primary Care Networks and the

notes from these discussions will be circulated separately. Minute No S&ALB-2019-02.030: Item 13 – Primary Care Update

13.1 The monthly Primary Care Update had been previously circulated for Members information and there

were no further questions about this. Minute No S&ALB-2019-02.031: Item 14 – Commissioning Update

14.1 The monthly Commissioning Update had been previously circulated for Members information and there were no further questions about this.

Minute No S&ALB-2019-02.032: Item 15 - Date and Time of Next Meeting

17.1 The next formal meeting will be held on: Thursday 21 March 2019 at Severn Fields Medical Practice,

Sundorne Road, Shrewsbury SY1 4RQ commencing at 2.00pm. Future 2019 meeting dates:

Thursday 21 March Thursday 11 April – venue is University Centre Shrewsbury Wednesday 22 May - PLT Thursday 20 June Thursday 18 July Thursday 15 August Thursday 19 September Thursday 17 October Thursday 21 November

Thursday 19 December

Further PLT dates to be confirmed.

Signed: ....……………………………………………….. Date: ………………

Dr Deborah Shepherd, Locality Chair


1




Name of Committee:

Shrewsbury and Atcham Locality commissioning Committee

Date of Meeting:

Thursday 21st March 2019

Chair:

Dr Deborah Shepherd


Discussion regarding the revision of the format and content of locality meetings to make them

more appropriately focussed on clinical commissioning issues.

Prescribing presentation on issues around polypharmacy

Presentation from the West Midlands Integrated Urgent Care Team – description of the care

model and the role of the Clinical assessment service. Members gave feedback on the

performance of the service and suggestions for improvement.

Presentation on the Shropshire Care Closer to Home project – information on the various

phases of the programme, description of the contribution of local GPs to the design, anticipated

benefits and challenges.


Shropshire CCG Governing Body – 08.05.19 Agenda Item: GB-2019-05.084b

Shrewsbury & Atcham Locality Board Minutes – 21 March 2019 Page 1 of 7


Dr D Shepherd (Chair) CCG Locality Chair & Locum GP Attended

Dr J Pepper Belvidere Attended

Caroline Davis Belvidere Attended

Dr M Fallon Claremont Bank Apologies

Jane Read Claremont Bank Apologies

Emily Marston Claremont Bank Attended

Dr E Baines Marden Attended

Zoe George Marden Attended

Dr Julia Visick Marysville Apologies

Dr Pippa Hine Marysville Attended

Izzy Culliss Marysville Attended

Dr Sarah Watton Mytton Oak Apologies

Adrian Kirsop Mytton Oak Attended

Dr R Bland Pontesbury Attended

Heather Brown Pontesbury Apologies

Dr H Callahan Radbrook Green Attended

Angela Treherne Radbrook Green Apologies

Dr P Rwezaura Riverside Attended

Tracy Willocks (Vice Chair) Riverside Attended

Dr D Martin Severn Fields Attended

Tim Bellett Severn Fields Attended

Dr L Davis South Hermitage Attended

Caroline Brown South Hermitage Apologies

Dr E Jutsum The Beeches Apologies

Kim Richards The Beeches Apologies

Helen Steel The Beeches Attended

Jo Beason Whitehall Attended

Dr K McCormack Worthen Attended

Cheryl Brierley Worthen Apologies

Roland Brown Severn Fields PPG Apologies

Jenny Birch Belvidere PPG Apologies

Tina Sandford Severn Fields PPG Apologies

Julian Birch Belvidere PPG Attended

Dr Julian Povey CCG Chair Apologies

Dr Simon Freeman CCG Accountable Officer Apologies

Dr Julie Davies CCG Director of Planning and Performance Apologies

Nicky Wilde CCG Director of Primary Care Attended

Jenny Stevenson CCG Locality Manager Attended

Heather Clark (Minute Taker) CCG Personal Assistant Attended


Lisa Pascall CCG Locality Technician [Item 6] Attended

Dr Finola Lynch CCG GP Board Member and Vice-Chair [Item 10] Attended Dr Catherine Beanland South Locality GP [Item 10] Attended Dr Clare Hurst South Locality GP [Item 10] Attended Dr Yvonne Vibhishanan North Locality GP [Item 10] Attended Dr Pir Shah Clinical Lead, West Midlands Integrated Urgent Care [Item 9] Attended

Sarah Makin Arden & GEM CSU, Head of Engagement, Communications and Marketing [Item 9]

Attended

Minutes of the

Shrewsbury & Atcham Locality Board Meeting

Thursday 21 March 2019

Board Meeting Room, 2nd Floor, Severn Fields Health Village,

Sundorne Road, Shrewsbury, SY1 4RQ



Minute No S&ALB-2019-03.033: Item 1 - Welcome & Apologies

1.1 Dr Deborah Shepherd, Locality Chair, welcomed and thanked Members for attending and introductions were made. Apologies were noted as above.

Minute No S&ALB-2019-03.034: Item 2 – Members’ Declarations of Interests

2.1 Members were reminded of the governance requirement to submit annually a new completed and signed declaration of interest form, copies of which were tabled. There were no further interests declared for items included on the agenda.

2.2 Dr Shepherd explained that there were a number of forms now out of date and needed to be completed

again; Members with out of date forms should have received an email from Heather Clark.

ACTION: Members were reminded to submit a new completed and signed declaration of interest form and return to Miss Heather Clark. ([email protected])

Minute No S&ALB-2019-03.035: Item 3 – Minutes of Meeting Held on 21 February 2019 and Actions 3.1 The minutes of the previous meeting, held on 21 February 2019, were accepted as a true and accurate

record and were signed by the Chair. 3.2 Minute No S&ALB-2019-02.023 – Prescribing Update – Jenny Stevenson explained that feedback

received stated there wasn’t anything specific about children being exempt from the OTC guidance. Children from low income families requiring vitamins will be provided with Healthy Start vitamins free of charge; the OTC guidance does not apply to this scheme. If children are not eligible for free vitamins they can be purchased at a price of £3 for an 8 week supply. If a child needs vitamins due to deficiency e.g. iron, vitamin D, they would be eligible for an NHS prescription. Pre-term neonates will usually be discharged from hospital on multivitamins and may require further supplies from the GP on prescription; this is also exempt from the guidance.

3.3 Minute No S&ALB-2019-02.025 – LAC and SEND – Jenny Stevenson advised that she was still awaiting

a response from Carol Richardson in regards to the action on EHCP medical questionnaires.

ACTION: Jenny Stevenson to chase Carol Richardson for response in regards to her action from the February meeting - Carol Richardson to look into whether the Local Authority are sending and receiving EHCP medical questionnaires to and from practices and to work with BI team on an electronic form for the questionnaires.

Minute No S&ALB-2019-03.036: Item 4 – Matters Arising


Minute No S&ALB-2019-03.037: Item 5 – Locality Chair Update 5.1 Dr Shepherd advised that Dr Simon Freeman, the CCG Accountable Officer’s last day is on Monday 25

th

March 2019. The new Accountable Officer, David Stout, has been invited to the meeting in April to introduce himself.

5.2 Dr Shepherd stated that finances were still extremely challenged and the CCG were unlikely to meet the

control total this year. There is also a significant gap for next year’s budget and the CCG are in negotiations with NHS England about this. Claire Skidmore, Chief Finance Officer, has been invited to the meeting in April to talk about this.

5.3 Dr Shepherd explained that a review of the locality meetings had taken place to look at the format of the

meetings and how to make them more commissioning focused. A draft guidance document had been provided for Members to review.

5.4 Dr Shepherd added that the other localities were trialling having a separate provider meeting before or

after their main Locality Board meeting and asked Members if this was something they wanted to do. Dr McCormack stated that meetings can drag on sometimes but were good when there were formative educational discussions; splitting the provider and commissioning function is complicated and it was up to the CCG to do this. Dr McCormack stated that usually Members could not influence commissioning




and were given updates about what had already been decided, and also that information about updates and what was happening at the CCG were not needed and could be read outside of the meeting. Further discussion took place about this and Members agreed that there was an overlap between them being providers and commissioners and that a separate meeting was not needed at this time.

5.5 Dr Shepherd advised that the Locality Boards would be aiming to bring things earlier for discussion so

that Members can feed into them. These items would be in draft form but Members would be able to comment on them about what will and will not work. There will be fewer external speakers and more commissioners attending the meetings.

5.6 Dr Baines stated that meetings can sometimes become hostile when Members hear things they don’t

agree with or are told there are ways they should be doing certain things without being given enough notice or a chance to influence them. Dr Shepherd agreed that in the past there had been a tendency for presenters to attend and tell Members what they should be doing and future meetings will be moving away from this with more chance for members to give their opinions. Dr Shepherd suggested that Members could think about having some rules of engagement for everyone attending the meetings if required. The guidance document that is being created could be shared with presenters before they attend the meeting so they know what to expect.

5.7 Dr Shepherd talked about the role of Practice Managers at the meetings as this had been raised

previously. She advised that in the terms of reference each practice has a GP and Practice Manager in the core membership of the Locality Board. The terms of reference are due to be reviewed and if the locality would like to change this it would need to be the same for all three localities, be in line with the CCG constitution, and be approved by the Governing Body. Dr Shepherd suggested that the membership was not changed straight away and that it would be better to see how the meetings evolved and review the terms of reference sometime in the future.

ACTION: Members were asked to email any ideas or suggestions about locality meetings to Dr Shepherd. ([email protected])

5.8 Dr Shepherd mentioned practice visits, and that as it was a busy time of year these would be postponed,

but she would be contacting practices later in the year to arrange these. If a visit was needed in the meantime, practices could request a visit earlier.

Minute No S&ALB-2019-03.038: Item 6 – Prescribing Update 6.1 Clare Michell-Harding talked through the update provided which concentrated on Polypharmacy and

Secondary Care. The Polypharmacy update covered prescribing comparators which showed the percentage of patients prescribed 15 or more unique medicines, anticholinergic burden (ACB) in the elderly and deprescribing. The update showed that Shropshire CCG were doing well compared to other areas when looking at the percentage of patients prescribed 15 or more unique medicines. The ACB work to identify patients at increased risk would be a large piece of work but could be something to look at in the future. Currently the Medicines Management Team were unable to commit to this as it was not known how difficult it would be to obtain the data needed, but practices will be informed once a decision has been made.

6.2 A Tresiba policy had been approved and will be on the CCG website soon. Queries were raised

previously about whether this was for type 1 or 2 diabetes patients; this was confirmed that it is for type 1 patients, with a small cohort of type 2 patients. This would only be following an MDT with the Diabetes Specialist Team in secondary care, and prescribing responsibility would remain with secondary care until the patient is stabilised. Freestyle Libre education will be sent out soon. If patients present the advice is that they are not sent straight away for flash glucose monitoring, this needs to be done in a monitored way at their next diabetes review, or if they are admitted to hospital it could be considered then.

6.3 Clare Michell-Harding introduced Lisa Pascall who is the Pharmacy Technician for the Shrewsbury and

Atcham Locality. Ms Michell-Harding advised that Indi Kaur had now left the CCG and the replacement Pharmacist for the locality would be starting at the end of May and will be coming out to visit practices in June.

Minute No S&ALB-2019-03.039: Item 7 – Open Discussion – “Hot Topics” from Practices





Minute No S&ALB-2019-03.040: Item 8 – PPG Update and Feedback

8.1 Julian Birch advised that there was a meeting on 20

th March 2019 and Steve Ellis and Nicky Wilde

attended to talk about the STP Primary Care strategy. 8.2 Mr Birch questioned the role of patients and the Shropshire Patient Group (SPG) as currently only 10 out

of 41 practices were represented. He asked about PPGs at practices and why some no longer exist and if they are valuable, and whether the SPG still had a purpose. Dr Baines stated that Marden Medical Practice had a very active patient group and are involved in the practice, the SPG and provide a lot of support. There was a concern that the groups do not cover a complete cross section of the patient population. Tracy Willocks advised that her practice had tried numerous ways of engaging patients such as virtual and face to face groups but that the PPG were thinking of disbanding as they could not get enough people involved.

8.3 Mr Birch asked how patient representatives were selected to be involved in projects and services as

currently it appeared that the CCG were selecting patients rather than the SPG. Dr Lynch advised that for the Care Closer to Home Programme the original patient representative stepped away as given the complexity and nature of some of the work he didn’t feel he was the right person as the role required certain skills and experience. The process used to find a patient representative involved patients sending in a brief letter introducing themselves with a short CV about what they had done and why they were interested in the role. Three patients were selected, one to be on the programme board and others involved in other areas of the programme.

Minute No S&ALB-2019-03.041: Item 9 – Integrated Urgent Care 9.1 Dr Pir Shah, Clinical Lead for West Midlands Integrated Urgent Care, gave a presentation to Members

and covered the following points:

What does Integrated Urgent Care in the West Midlands look like

The model

Information about CAS (Clinical Assessment Service), *5 (paramedics referring to CAS), *6

(nursing homes referring to CAS)

Targets, performance and data

Challenges and innovations

9.2 Members advised that the 111 sheets they receive contain a lot of information that isn’t needed and are difficult to read, this creates a clinical risk. Dr Shah advised that the team were aware of this and were looking into other methods.

9.3 Discussion took place about 111 pathways and thresholds being set too low. Dr McCormack stated that

around 96% of calls that come into 111 are passed on and something different was needed. Dr Shah advised that he was aware conversations had taken place about the possibility of using other software for 111; but that there was anxiety around changing something like this. A question was asked about clinicians being involved in 111. Dr Shah advised that there would not be enough GPs to take all the calls; there needs to be a better process or a better algorithm instead.

9.4 Dr McCormack stated that 111 had created a huge burden on 999, A&E and GPs and had increased

patient expectation. Dr Shah explained that this was because of non-clinician involvement and the risk-averse algorithm. Conversations had been taking place with 999 about outcomes and whether more calls could be referred to CAS.

9.5 Dr Shah advised Members to continue to provide feedback through HPF (Health Professional Feedback)

forms, for example home visits that are inappropriate or if Members were not happy with outcomes of 111 calls. Members were not aware of HPF forms; Dr Shah advised that he would email the details to Jenny Stevenson.

ACTION: Dr Pir Shah to email details about HPF forms to Jenny Stevenson.

9.6 Dr Baines asked about how frequent callers were dealt with and percentage of calls to 111 from

Shropshire. Dr Shah advised that Shropshire used the 111 service about the same amount as other areas; he highlighted Sandwell as a heavy user of the service. For frequent callers he advised that the team highlight these patients through Adastra, Members advised that this information was not available to them.



ACTION: Dr Pir Shah to look into how information about frequent 111 callers can be shared with practices.

9.7 Discussion took place about WMAS (West Midlands Ambulance Service), the increase in 999 calls and

models of payment. Dr Shah advised that the new Medical Director at WMAS was keen for GPs to be involved for some 999 calls and initial ideas had been discussed about GPs taking calls for category 3 and 4 calls (falls, faints, collapses). As well as being paid for conveying patients, WMAS also have targets to meet once they get to hospital which they are not currently meeting.

9.8 Dr Shepherd asked about response times of ambulances and prioritisation as she was aware of different

response times in different areas that aren’t always related to rurality. Dr Shah advised that this conversation hadn’t taken place yet, but that the guidelines for category 1 calls are within 15 minutes.

9.9 Dr Shepherd asked about calls for patients that collapse in GP surgeries and why they are not prioritised.

These patients have already been triaged by a GP and assessed as in urgent need; the GP would also have done everything they could possibly do for the patient. Dr Shah advised that he had previously had conversations about this and was told by WMAS that they do not take longer for these patients. Dr Shah asked Members to email him cases where they have taken longer and he would raise this with WMAS. Dr Shah explained that it was made clear by WMAS that they do not downgrade calls based on location. Some Members advised that they had been told calls were downgraded if a defibrillator is on site.

ACTION: Members to share details of cases with Dr Shah where WMAS have taken longer to attend for calls for patients in GP surgeries.

Minute No S&ALB-2019-03.042: Item 10 – Care Closer to Home 10.1 Dr Finola Lynch talked through the care closer to home presentation which covered the following areas:

The problems the CCG is trying to solve

Information about phase 1 Frailty Intervention Team

Information about phase 2 risk stratification, case management and pilot sites

Information about the services in phase 3: Rapid Response, DAART, Crisis Intervention, Hospital at Home, Step-up beds

Role of the GPs on the working group

Benefits to GPs and Patients

Challenges by GPs

Next steps 10.2 Dr Lynch stated that the team needed a few more practices to be control sites for phase 2 and asked if

any other practices were interested, the team would only need access to data at the practice to compare whether the service is having the impact it hoped for.

ACTION: Members to contact Dr Finola Lynch if they are interested in being a control site for care closer to home phase 2. ([email protected])

10.3 Dr McCormack explained that his initial concern was that GPs needed to be insulated from continuous

care needs in the community, and there needed to be a clear handover at both ends of the service. He added that the numbers in the specifications were ambitious and the service would not save money, but was aware this was about improving outcomes for patients and providing a service preferred by patients. Dr Lynch explained that this was not being done to save money, and that the CCG think that the money is currently in the wrong place and needed to be moved from acute services to the community. There will need to be a huge culture change in all organisations and health professionals involved. Dr Lynch added that currently there were not any specifications for community services, which meant that the CCG were unable to challenge providers.

10.4 Dr Vibishanan agreed with the worries about finances and stated that the service would be fantastic if

affordable. Currently there are always ongoing calls between organisations in regards to taking responsibility for patients; if responsibility is in one place and with one team it would be better for patients. Dr Vibishanan raised concerns about workforce needed for the service as currently the District Nursing Team were already stretched. She also had concerns about work coming back to GPs and that the service specifications needed to be clear about this. Dr Hurst agreed with the concerns about clinical responsibility especially for rural practices and questioned whether SaTH (The Shrewsbury and Telford Hospital Trust) doctors would be able to help or whether GPs would end up with extra work.

10.5 Dr Beanland agreed with finance and workforce concerns and also advised that the South Locality were

worried about this service and whether work would come back to GPs especially in the rural areas. Dr




Beanland mentioned something she had read about research conducted by Southwark and Lambeth for GP screening and care plan programmes for older patients. Their findings showed a significant increase in costs for the NHS due to identification of unmet needs.

10.6 Dr Shepherd stated that the impression given was that there would be a dedicated Clinical Lead for the

service who would take responsibility for patients, and if this was the case the service specification should state this clearly. This would mean any concerns from staff should go to the Clinical Lead and not back to GPs. Dr Lynch advised that she had met with clinicians in SaTH about these concerns and there was an overlap with this service and work they had started in the past, they do have an interest in this work; MPFT (Midlands Partnership Foundation Trust) and their Consultant Psychiatric Team are also closely involved and keen to support.

10.7 Dr Baines asked if there would eventually need to be some GP input into the service e.g. looking at

outcomes and influencing longer term. Dr Lynch advised that there may be a need to have a conversation with GPs in the care planning stage, but patients will have an individual in the team case managing them and will know them well, the case manager will be allocated depending on need.

10.8 Dr Baines asked if the team would have capacity to deal with patients at end of life. Dr Lynch advised

that this was a possibility and they would take it on a case by case basis. For example, cancer is not specifically mentioned in the service specification as there are already services for cancer, but the team may be involved with the hospice or could refer into the hospice. Dr Lynch added that the team would want others to refer into the service too, such as the ambulance service. Dr Vibishanan added that there was a Macmillan pilot in Oswestry that may also be able to join up with this service.

10.9 Dr Pepper asked about the Crisis Team and if there was any part of the service that would have ongoing

case management for mental health and links with the Community Mental Health Service. Dr Lynch advised that the service could link in with the MPFT dementia service which had turned their ward staff into both ward and community staff. She explained that patients could now be discharged home from the ward when they are ready, with support, and they could also call the ward directly if they needed help again.

10.10 Dr Beanland added that only phase 2 was being piloted at this stage and would like to know when phase

3 will be piloted as she had concerns about phase 3 starting and taking staff from other services. Localities need oversight of this to ensure staff are trained and there is sufficient doctor cover. Dr Pepper added that if there is a trial of phase 3, it would be a good idea to have rural practices involved.

Minute No S&ALB-2019-03.043: Item 11 – Primary Care Update

11.1 The monthly Primary Care Update had been previously circulated for Members information and there

were no further questions about this. Minute No S&ALB-2019-03.044: Item 12 – Commissioning Update

12.1 The monthly Commissioning Update had been previously circulated for Members information and there were no further questions about this.

Minute No S&ALB-2019-03.045: Item 13 – Any Other Business


Minute No S&ALB-2019-03.046: Item 14 - Date and Time of Next Meeting

14.1 The next formal meeting will be held on: Thursday 11 April 2019 in Room SGH215, Second Floor,

University Centre Shrewsbury, Guildhall, Frankwell Quay, Shrewsbury, Shropshire, SY3 8HQ commencing at 2.00pm.

Further 2019 meeting dates: Wednesday 22 May – PLT (further PLT dates to be confirmed)

Thursday 20 June Thursday 18 July Thursday 15 August Thursday 19 September



Thursday 17 October Thursday 21 November

Thursday 19 December

Signed: ....…………………………………………………….. Date: …………………

Dr Deborah Shepherd, Locality Chair

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